
LIBRARY OF CONGRESS. 



Chap. _ll... Copyright No, 



Shelf. 



Ja. 



837 



UNITED STATES OF AMERICA. 



ESSENTIALS 



OBSTETEICS 



BY 



CHARLES JEWETT, A.M., M.D., Sc.D., 

PROFESSOR OF OBSTETRICS AND PEDIATRICS IN THE LONG ISLAND COLLEGE HOSPITAL 
AND OBSTETRICIAN TO THE HOSPITAL. 

ASSISTED BY 
/ 

HAROLD F. JEWETT, M.D. 



ILLUSTRATED BY 80 WOODCUTS AND 3 COLORED PLATES 







LEA BROTHERS & CO., 

NEW YORK AND PHILADELPHIA 

1897. 



C 




Entered according to the Act of Congress in the year 1897, by 

LEA BROTHERS & CO., 
In the Office of the Librarian of Congress. All rights reserved. 



DOK.NAN, PRINTER 



PREFACE 



The object of this volume is to place the Essentials of 
Obstetrics within easy grasp of the student. With this 
aim in view conciseness and clearness have been consulted, 
even at the risk sometimes of being dogmatic, and a sys- 
tematic and logical arrangement has been observed. Most 
attention has been given to practical topics. Theoretical 
discussions, matters of merely historical interest and elabor- 
ation of details have in the main been purposely excluded. 

Works of this character in the author's experience, have, 
within their proper limits, a distinct value in medical 
teaching. The pupil in any department of learning suc- 
ceeds best by first mastering its elements. To the beginner 
cyclopaedic works are confusing. It is seldom that the 
average medical student has the necessary mental training 
to analyze his subject for himself. This must be done 
for him till he is well-grounded in the rudiments. The 
foundation well laid, a complete and systematic knowledge 
of the subject becomes a matter of comparatively easy 
attainment. 



vi PREFACE. 

If these pages shall be found useful as an introduction 
to the more elaborate treatise, and as a guide in following 
the didactic and the practical teaching of the college course, 
the author's object will have been gained. 

Charles Jewett. 

330 Clinton Ave., Brooklyn, N. Y. 
September, 1897. 



CONTENTS. 



CHAPTER I. 

ANATOMY OF FEMALE GENITAL ORGANS. 

PAGES 

External genitals — The vagina — Internal genitals . . 13-40 
CHAPTER H. 

PHYSIOLOGY OF PREGNANCY. 

Physiology of the ovum — Effects of pregnancy on the ma- 
ternal organism — Signs of pregnancy — Duration of 
pergnancy — Hygiene of pregnancy .... 41-88 

CHAPTER III. 

PHYSIOLOGY OF LABOR. 

The mechanical factors of labor — Clinical and mechanical 

phenomena of normal labor — Management of labor 89-159 

CHAPTER IV. 

PHYSIOLOGY OF THE PUERPERAL STATE. 

Course and phenomena of the puerperal state — Management 
of the puerperal state — Lactation and nursing — The 
child — Condition at birth — Management of the newborn 
child — Artificial feeding — Disorders of the newborn 
infant 160-192 



viii CONTENTS. 

CHAPTER V. 

PATHOLOGY OF PREGNANCY. 

PAGES 

Diseases of the deciduse — Anomalies of the amnion and the 
liquor amnii — Disease of the chorion — Anomalies of the 
placenta — Anomalies of the umbilical cord — Pathology 
of the foetus — Abortion — Premature labor — Ectopic ges- 
tation — Pernicious vomiting and other disorders of 
pregnancy 193-223 

* CHAPTER VI. 

PATHOLOGY OF LABOR. 

Anomalies of the mechanism — Anomalies of the expelling 
powers — Anomalies of the passages — Anomalies of the 
passenger — Anomalies of labor arising from accidents or 
disease 224-290 

CHAPTER VII. 

PATHOLOGY OF THE PUERPERAL STATE. 

Puerperal insanity— Galactorrhea— Mastitis — Puerperal in- 
fection 291-305 

CHAPTER Vlir. 

OBSTETRIC SURGERY. 

Induction of premature labor — Induction of abortion — Re- 
moval of an abnormally adherent placenta — Eorceps — 
Version — Csesarean section— Porro operation— Symphy- 
siotomy — Embryotomy 306-350 



ESSENTIALS OF OBSTETRICS 



CHAPTER I. 

ANATOMY OF FEMALE GENITAL ORGANS. 

For convenience of description the genital organs of the 
female may be divided into the external and the internal 
genitals, and the vagina, which connects the one group with 
the other. 

The external genitals of the female together constitute the 
'pudendum or the vulva. 

External Genitals. 

The external sexual organs of the female are the mons 
veneris, the labia majora, the labia minora, the clitoris and 
the hymen. 

The Mons Veneris, or the mount of Venus, is the 
fleshy prominence which overlies the anterior aspect of 
the pubic bones. Its surface is slightly convex. It is 
bounded laterally by the groins, above by the hypogastric 
fold, and below it merges into the labia majora. It consists 
essentially of fat supported by a reticular framework of 
fibrous and elastic tissue. Fibres of elastic tissue, some of 
which are derived from the superficial abdominal fascia, run 
through the adipose layer in all directions. The round liga- 
ment may be traced into the mons on either side. Its 

2 



14 



ESSENTIALS OF OBSTETRICS. 



integument, which is somewhat thicker than that of the ab- 
domen, becomes invested at puberty with a growth of short, 
crisp, curly hair ; it abounds in sebaceous and in sweat- 



FlG. 1. 




Vulva of the virgin. 1. Greater lip of right side. 2. Fourchette. 3. Small lip. 
4. Clitoris. 5. Urethral orifice. 6. Vestibule. 7. Orifice of the vagina. 8. Hymen. 
9. Orifice of the vulvo-vaginal gland. 10. Anterior commissure of greater lips. 
11. Anal orifice. 

glands. The hairy growth extends an inch or more above 
the level of the pubic bones. It is a peculiarity of the 
female that the hair of the pubic region is limited above by 
a sharply denned straight or convex line. 



ANATOMY OF FEMALE GENITAL ORGANS. 15 

The Labia Majora, or larger lips, are two prominent 
rounded folds springing from the mons veneris and ex- 
tending downward and backward on either side of the 
median line. At full development they lie in contact with 
each other in the young nullipara, except when the thighs 
are strongly abducted — vulva connivens. When shrunken 
from loss of fatty tissue in old age, or from the effects of 
childbirth, the labia minora protrude between them — vulva 
hians. They are thickest in front, and taper from before 
backward. The point of contact in front is spoken of as 
the anterior, and that behind as the posterior commissure of 
the vulva. There is, however, no true commissure in the 
sense of a connecting band at either point. 

The covering of the labia majora is skin. The outer sur- 
faces, which are of a somewhat darker color than the sur- 
rounding integument, are supplied with hair which is most 
abundant anteriorly; the inner surfaces resemble mucous 
membrane, but are sparsely covered with fine hairs. Both 
surfaces abound in sebaceous and in sweat-glands. Their 
internal structure consists chiefly of elastic and adipose 
tissue, and includes a rich venous plexus. Immediately be- 
neath the skin is a layer of smooth muscular fibres anal- 
ogous to those of the dartos in the male. Within this is 
the pudendal sac. It is made up of elastic fibres, and is 
attached by its neck to the external inguinal ring. Its 
fundus reaches nearly to the posterior vulvar commissure. 
Its cervix contains elastic and adipose tissue. The remains 
of the canal of Nuck may sometimes be traced into the 
pudendal sac. Each round ligament of the uterus termin- 
ates in the corresponding labium. The labia majora are the 
analogue of the scrotum in the male. 

The Labia Minora, or Nymphae, the smaller lips, 
are two thin folds of delicate skin lying between the labia 



16 ESSENTIALS OF OBSTETRICS. 

majora. They are widest toward their anterior extrem- 
ities, narrowing gradually from before backward. When 
at rest their inner surfaces are in contact. The outer sur- 
faces merge into the labia majora, the inner are continuous 
with the vestibule. Anteriorly each subdivides into two 
subsidiary folds. The superior folds join in front of the 
clitoris to form the prepuce, the inferior unite and are 
attached to the under surfaces of the glans to form the frae- 
num of the clitoris. Posteriorly they are united by the 
fourchette. 

In Bush women and in many Hottentots the smaller labia 
are hypertrophied, reaching half-way to the knees ; this 
overgrown structure is known as the Hottentot apron. 

In the virgin the nymphse present the appearance of 
mucous membrane ; after long exposure from gaping of the 
vulva they look like skin. They are destitute of hairs and 
of sweat-glands. Sebaceous glands are found on both sur- 
faces. In general the histological characters of the outer 
surfaces are those of skin, not of mucous membrane. The 
minute anatomy of the inner, surfaces lies between that of 
skin and mucous membrane. 

The internal structure of the nymphse includes some 
bundles of unstriped muscular fibre and a superficial capil- 
lary venous plexus, but no fat. 

The labia minora are richly supplied with nerve-fibres. 

The Fourchette, or Frenulum Vulvae, is a trans- 
verse fold of skin immediately in front of the posterior 
vulvar commissure. It is scarcely apparent, except when 
put upon the stretch by separating the labia. It then ap- 
pears as a tense transverse fold between the posterior com- 
missure and the hymen. In the nulliparous woman its 
distance from the anal orifice is 3 cm. (1 \ inch) ; from 
the base of the hymen nearly 1 cm. (J inch). 



ANATOMY OF FEMALE GENITAL ORGANS. 17 

The Fossa Navicularis is a boat-shaped space which 
appears between the hymen and the fourchette when the 
labia are separated. 

The Rima Pudendi is the median cleft between the labia 
of the right and the left sides. 

The Clitoris is the analogue of the penis in the male. 
It is situated in the median line below the anterior vulvar 
commissure. It is a very small cylindrical body, and is 
about one inch in length during erection. It is curved with 
its convexity outward. Like the penis it has two corpora 
cavernosa and a glans, but no corpus spongiosum, and is 
imperforate. Continuous with the corpora cavernosa are the 
crura by which the clitoris is attached to the ischiopubic rami. 
The body is attached to the pubic bones by the suspensory 
ligament. It is concealed behind the skin and is enclosed 
in a firm fibrous sheath. Its internal structure is made up 
chiefly of cavernous tissue. The only visible portion of the 
organ is the glans, and this lies partly concealed in the 
preputial fold formed by the anterior layers of the nymphre, 
as has already been described. The glans during erection 
has a thickness of about 5 mm. Its mucous membrane is 
richly supplied with nerve-papillae. 

Arteries and Vein. It has two arteries, the dorsal and 
the profunda, and a dorsal vein. The vascular supply is 
from the pudic artery. The dorsal vein empties into the 
vesical plexus and communicates freely with all the sur- 
rounding venous plexuses. 

The nerve-supply is four or five times more abundant 

than that of the penis. The clitoris is the chief seat of 

voluptuous sensation in the female. 

Glands. A few sebaceous follicles are to be found on the 
glans. 

The Vestibule. This is the triangular surface bounded 



18 



ESSENTIALS OF OBSTETRICS. 



laterally by the labia minora and below by the margin of 
the vaginal orifice. Its covering is mucous membrane. At 
its apex is the glans clitoridis. At the middle of its base, 
or immediately above it, is the meatus urethrae. This ap- 
pears as a small tubercle or prominence with a median cleft. 
The meatus lies 2 cm. (f inch) below the glans clitoridis, 
and 2.5 cm. (1 inch) above the fourchette, in the nullipara. 
An intricate plexus of veins immediately underlies the 
mucous membrane. This is the 'pars intermedia, so called 
from the fact that it connects the opposite vestibular bulbs 
with each other and with the veins of the clitoris. 



Fig. 2. 




The bulbi vestibuli. 



The bulbi vestibuli are two leech-shaped masses of veins 
about 3.5 cm. in length, and are situated one on either side 



ANATOMY OF FEMALE GENITAL ORGANS. 19 

of the mesial line behind the labia, opposite the vaginal orifice 
and the base of the vestibule. In extent they reach from the 
level of the posterior margin of the vaginal orifice nearly to 
the clitoris. They lie between the bulbo-cavemosus muscle 
and the vaginal wall, immediately in front of the triangular 
ligament. They communicate freely with the veins of the 
labia, the vagina, the perineum, the glans clitoridis, and with 
other neighboring venous plexuses. Each is enclosed in 
a fibrous sheath. Their internal structure comprises, in addi- 
tion to venous plexuses and connective tissue, some smooth 
muscular fibres. The bulbs correspond to the bulbs of the 
urethra in the male. 

The Vulvo-vaginal Glands, Glands of Bartholin or Duverney. 
These are two reddish-yellow bodies varying in size from 
a pea to an almond, lying one on each side of the posterior 
portion of the vaginal orifice, behind the anterior layers of 
the triangular ligament, sometimes behind the posterior layer. 
They are partly covered by the lower extremities of the 
bulbi vestibuli. Their ducts, about 1.3 cm. (J inch) in length, 
run along the inner aspects of the bulbi vestibuli, opening 
iust without the base of the hvmen at the sides of the vagi- 
nal orifice. The secretion, which is a yellowish tenacious 
mucus, is poured out freely under sexual excitement and 
during labor. 

The Hymen. The hymen appears usually as a septum, 
partially occluding the vaginal orifice when the labia are 
drawn apart. When at rest it protrudes as a loose fold in 
the vulvar fissure. According to Budin, it is a thinned-out 
fold of the vaginal v>all. Its most common form is that of 
a crescent, situated at the posterior margin of the introitus, 
with its concavity looking forward. It may, however, be 
annular, or may occupy the entire vaginal orifice, being either 
imperforate or cribriform — perforated with holes — or may 



20 ESSENTIALS OF OBSTETRICS. 

have a single central opening with a fimbriated edge. Its 
histological characters are similar to those of the vaginal 
wall, yet it has but few muscular fibres. It is usually torn 
at the first sexual approaches. An untorn hymen is not, 
however, an infallible mark of virginity, nor is a torn one 
necessarily evidence that sexual intercourse has been prac- 
tised. 

The Carunculae Myrtiformes. The carunculse myrti- 
formes are the remnants of the hymen torn in labor by the 
passage of the child. They appear as minute fleshy tuber- 
cles, three or four in number, skirting the vaginal orifice or 
at least its posterior margin. 

Vessels, Lymphatics, and Nerves of the Pudendum. 

Arteries. The arterial supply of the pudendum is de- 
rived from the superficial perineal branch of the internal 
pudic and from the external pudic artery. 

Veins. The veins accompany the arteries. They empty 
into the internal pudic and the inferior branch of the small 
sciatic. 

Lymphatics. The lymphatics go to the superficial inguinal 
glands, which in turn communicate with the internal or with 
the external inguinal glands. 

Nerves. The nerve-supply, which is abundant, is from 
the superficial perineal nerve, which is given off from the 
pudic, the inferior pudendal nerve, which comes from the 
small sciatic, and from the inferior hypogastric plexus of 
the sympathetic. 

The Vagina. 

The vagina is that part of the genital tract between the 
uterus and the pudendum. Its direction is nearly parallel 
with the plane of the pelvic brim. It terminates below in 



AXATOMY OF FEMALE GEXITAL OEGAXS. 21 

the hymen or its remnants ; the upper part of the tube, 
which surrounds the cervix, is the roof or fornix of the 
vagina. The part of the upper extremity behind the cervix 
is the posterior, that in front the anterior fornix -; the lateral 
portions of the vaginal roof are spoken of as the lateral 
fornices. The posterior is deeper than the anterior fornix, 
owing to the higher attachment of the posterior vaginal 
wall to the cervix. 

Relations. As already stated, its upper extremity is 
attached to the uterine cervix a little below the middle of 
its length, the lower portion of the cervix projecting into 
the vagina nearly at a right-angle. The posterior wall for 
about one-fourth of its length is in relation at the vaginal roof 
with the retro-uterine fold of peritoneum, the cul-de-sac of 
Douglas. Its lower end is united with the so-called peri- 
neal body: at its middle portion, over about half its length, 
it is connected with the rectum by a loose connective tissue. 
The upper half of the anterior wall is loosely attached to 
the bladder; the lower half is intimately connected with the 
urethra, the latter being incorporated in it. 

Laterally the fornices are in relation with the bases of the 
broad ligaments : below the fornices the vagina is attached 
on either side to the levator ani fascia. 

The recto-vaginal septum. The united portions of the 
rectal and the posterior vaginal walls form the recto-vaginal 
septum. 

The vesico-vaginal septum is formed by the union of the 
posterior wall of the bladder with the anterior vaginal wall. 

The urethro -vaginal septum is the partition between the 
urethra and the vagina. 

The Shape of the vagina when distended is approxi- 
mately that of a truncated cone with its larger end up. 
When at rest it is a collapsed tube, the anterior lying in 



22 ESSENTIALS OF OBSTETRICS. 

contact with the posterior wall. Its cross-section in the 
adult presents the shape of an H, the limbs of which have 
a slight inward convexity. Its orifice, the introitus vagince, 
is nearly circular. The vaginal axis is approximately a 
straight line. 

The Size of the vagina is larger in women who have 
practised sexual intercourse than in virgins, and is much 
increased in child-bearing women. 

The length of the anterior wall in the virgin is 6.3 cm. 
(2J inches), that of the posterior wall 9 cm. (3J inches) or 
a little more. The walls, however, are extremely distensi- 
ble, and in parous women they become permanently en- 
larged and relaxed, sometimes attaining the length of 10 to 
12 cm. (4 to 4§ inches). The width of the canal at the 
widest part is about 4 cm. (If inch) in the virgin; in 
women who have borne children it is frequently 7 cm. (2f 
inches). 

Structure. The vagina has three coats : the external 
or fibrous coat ; the middle or muscular coat ; the internal 
coat or mucous membrane. 

1. The fibrous coat is a prolongation of the recto-vesical 
fascia. 

2. The muscular coat consists of an inner circular and an 
outer longitudinal layer of unstriped muscular fibres. It 
is thickest near the vaginal orifice, thinnest in the upper 
part of the vagina. A band of voluntary muscular fibres 
(the bulbo-cavernosus muscle) encircles the vaginal orifice. 

3. The mucous coat is of a light pink color. It presents 
two median ridges, one on the anterior and one on the pos- 
terior wall. Transverse ridges, cristae, run outward on 
either side from the longitudinal ones. The median columns 
with the transverse crista are known as the columnae 
vaginae. These structures are more marked on the anterior 



ANATOMY OF FEMALE GENITAL ORGANS. 23 

than on the posterior wall, and on both are most conspicu- 
ously developed near the vaginal orifice. They are rarely 
found at all above the lower two-thirds of the tube. They 
are more or less completely effaced by child-bearing and by 
catarrhal inflammation of the vagina. The mucous mem- 
brane of the lower portion of the vagina lies in loose folds 
when the canal is closed. Its surface is studded with 
papillae. The epithelium is of the squamous variety. 

The arterial supply of the vagina is chiefly from the 
vaginal artery. The upper extremity of the tube receives 
branches from the uterine and the lower from the pudendal 
artery. These vessels anastomose with one another and 
with the vesical and rectal arteries. They all spring from 
the anterior division of the internal iliac. 

The veins correspond, but they first form plexuses en- 
tirely around the canal, one in the external coat and one 
in the submucous layer of connective tissue. They com- 
municate with the hemorrhoidal, vesical, pudendal and 
pampiniform plexuses. None of these veins has valves. 

The lymphatics. The lymphatics of the lower fourth of 
the vagina join with those of the pudendum, terminating in 
the inguinal glands. Those from the remaining portion of 
the vagina unite with those from the cervix uteri and 
empty into the internal iliac glands. 

The nerves are derived from the fourth sacral and the 
pudic of the spinal system, and from the lower hypogastric 
plexus of the sympathetic. 

Glands. The existence of true secreting glands, mucous 
glands, is by most anatomists denied. The vaginal secretion 
has an acid reaction, due to the presence of an acid-producing 
bacillus. 

The Urethra. Intimately connected with the lower 
portion of the anterior vaginal wall is the urethra. Though 



24 ESSENTIALS OF OBSTETRICS. 

not a generative organ, it is of obstetric interest, and is 
therefore described. 

Situation. From the midpoint of the base of the 
vestibule the urethra passes backward beneath the pubic 
arch to the bladder. In the lower three-fourths of its 
length it is embedded in the anterior vaginal wall. It is 
supported by the pubo-vesical ligament, and it pierces the 
layers of the triangular ligament in the same manner as 
does this canal in the male. The portion of the canal 
between the layers of the triangular ligament is encircled 
by the compressor urethrse muscle. The general direction 
of the canal is nearly parallel with the pelvic brim. 

Shape. Its shape is straight or very slightly curved, 
with its convexity downward and backward. When at rest 
its mucous membrane lies in longitudinal folds which are 
especially marked at the upper extremity. Its meatus is a 
vertical slit ; its vesical end is not funnel-shaped, as some- 
times described; the canal terminates abruptly in the bladder. 

Size. The length of the urethra is about 4 cm. (If 
inch), its average diameter is 6 mm. (J inch). It is largest 
at the vesical end, smallest at the meatus, and is very dis- 
tensible. 

Structure. It has two muscular coats, an outer circu- 
lar and an inner longitudinal layer and a mucous membrane. 

The epithelium of the urethral mucosa in the low T er por- 
tion of the tract is of the squamous type ; toward the upper 
extremity it is of the transitional form, like that of the vesical 
mucous membrane. 

The vascular and the nervous supply are the same as those 
of the vestibule. There is a plexus of large veins around 
the canal, and another plexus between the two muscular 
coats. 

Glands. Numerous lacunae and racemose glands are to 



ANATOMY OF FEMALE GENITAL ORGANS. 25 

be found on the surface of the mucous membrane. There 
are two tubular glands, known as Skene's glands, three- 
fourths of an inch in length, in the wall of the urethra near 
its floor, one on either side of the median line. Their 
orifices lie just within the meatus urethrae. 

Internal Genitals. 

These include the uterus, the Fallopian tubes and the 
ovaries. 

The Uterus. Situation. The uterus is situated in 
the cavity of the pelvis, between the bladder and the rectum, 
a little nearer to the sacrum than to the pubic bones. Its 
upper border is nearly in the plane of the pelvic brim, its 
lower border just above the level of a line drawn from the 
lower end of the symphysis pubis to the tip of the sacrum. 
The average direction of its long axis is nearly perpendicu- 
lar to the plane of the pelvic brim. Its position, however, 
is variable within normal limits. A full bladder pushes it 
bodily back toward the sacrum and tilts the fundus back- 
ward. A distended rectum displaces it forward. The upper 
portion of the uterus is in relation with the small intestines. 
The latter sink into the upper part of the utero-sacral space 
and sometimes into the utero-vesical pouch. Posteriorly 
the uterus is separated from the rectum by a fold of perito- 
neum, which dips down into the pelvic cavity to the dis- 
tance of an inch or more below the cervico- vaginal junction. 
This retro-uterine pouch of peritoneum will be more fully 
described later. Anteriorly the peritoneum covers about 
two-thirds the length of the uterus. That portion of the 
lower third of the uterus between the vagina and the peri- 
toneum is attached to the bladder by loose connective 
tissue. The lower uterine extremity projects into the 



26 



ESSENTIALS OF OBSTETRICS. 



upper end of the vagina to the extent of nearly 1.3 cm. (J 
inch). The axis of the uterus forms approximately a 

Fig. 3. 




Sagittal section of the pelvis, showing relations of generative organs. 1. Body 
of the uterus. 2. Cavity. 3. Neck. 4. Cavity of the neck. 5. Intra- vaginal part 
of the neck. 6. Vagina. 7. Vaginal orifice. 8. Bladder. 9. Urethra. 10. Vesico- 
vaginal wall. 11. Rectum. 12. Rectal cavity. 13. Anus. 14. Recto-vaginal 
wall. 15. Perineum. 16. Vesico-uterine cul-de-sac. 17, Utero-rectal cul-de-sac. 
18. Pubic symphysis. 19. Small lip. 20. Great lip 



ANATOMY OF FEMALE GENITAL ORGANS. 27 



right-angle with that of the vagina when the former organ 
is in its usual normal position. Laterally the uterus is in 
relation with the broad ligaments, presently to be described. 
Shape. The uterus is a hollow muscular body. Its 
shape is pyriform with its larger end uppermost. It is 
slightly flattened from before backward, its posterior and its 
upper surfaces are convex, its anterior aspect nearly flat. 
Its long axis is straight or slightly curved, with its concavity 
forward. 

Fig. 4. Fig. 5. 





Section of the nulliparous uterus, 
showing shape of corporeal and cervi- 
cal cavities, etc. 



Section of parous uterus, showing 
shape of corporeal and cervical cavi- 
ties, etc. 



measure- 



Size. a. Nulliparous uterus. The aven ^ 
ments of the nulliparous uterus are 2.5 cm. (1 inch) nearly 
in thickness antero-posteriorly, 3.8 cm. (1J inch) in width 
at the level of the Fallopian tubes, and 6.3 cm. (2J inches) 
in length. 

b. The parous uterus is approximately 2.5 cm. (1 inch) 
thick, 5 cm. (2 inches) wide, and 7.5 cm. (3 inches) long. 



28 ESSENTIALS OF OBSTETRICS. 

The transverse thickness of the lower end of the uterus, the 
cervix, is 3.1 cm. (1J inch). The organ undergoes marked 
atrophy after the menopause. 

Weight. The nulliparous organ weighs about 28 grams 
(1 ounce) ; in the parous woman the weight is 43 grams 
(1J ounce). 

Regional Divisions. The uterus presents two divisions, 
the body and the cervix. 

The body is approximately the upper half of the uterus 
in the nulliparous, the upper two-thirds in the parous woman. 

The isthmus is the slight constriction at the junction of 
the body and the cervix. 

The fundus is that part of the body above the level of the 
Fallopian tubes. 

Divisions of the Cervix, a. The infra-vaginal portion, 
or portio vaginalis, is that part of the cervix below the 
vaginal roof. Its average length in the parous woman is 1 
cm., a little less than J inch. 

b. The supra-vaginal portion is that part between the 
portio vaginalis and the isthmus.. Its length in the woman 
who has borne children is 1.5 cm., a little more than J inch. 

Uterine Cavity, a. The cavity of the body is somewhat 
triangular in shape in the nullipara, its anterior and poste- 
rior walls lying practically in contact. It has three open- 
ings, one communicating with the cervical canal and one 
with each of the Fallopian tubes. 

b. The cavity of the cervix is slightly flattened from 
before backward, and is laterally elliptical, thus having an 
irregular fusiform shape. 

The os internum is the upper orifice of the cervical canal, 
and is about 2.5 mm. (y 1 ^- inch) in diameter. 

The os externum, or os tincse, is the lower orifice, a little 
larger than the os internum. 



ANATOMY OF FEMALE GENITAL ORGANS. 29 

Structure. The mucous membrane of the body of the 
uterus is about 1 mm. (^ inch) thick at the fundus and 
more than twice that thickness at the centre of the body. 
No folds are to be observed in the mucosa of the body of 
the uterus except, perhaps, at the mouths of the Fallopian 
tubes. Its epithelium is of the ciliated columnar variety, 
the cilia, as stated by most anatomists, propelling toward 
the tubes. According to recent observations of Hofmeier, 1 
the ciliary movement is toward the external os. The mucosa 
of the body is firmly attached to the muscular structures. 
It abounds in tubular glands, many of which are bifurcated — 
the utricular glands. These are slightly tortuous, and, with 
few exceptions, extend to the muscularis ; some of them pene- 
trate it. They are lined with ciliated epithelium. Their 
secretion is alkaline. Dr. A. W. Johnstone ascribes to the 
corporeal endometrium a glandular character comparable to 
that of the lymph-tissues in the walls of the alimentary 
canal and of other adenoid structures. 

The mucous membrane of the cervix is thicker, firmer, 
and paler than that of the body, and it is united to the mus- 
cularis by a distinct submucous layer of loose connective 
tissue. On the anterior and on the posterior w^all it presents 
a pinnate arrangement of ridges known as the arbor vitce or 
palmce plicatce. This consists of a median longitudinal 
ridge from which well-marked lateral processes run out- 
ward and upward. Upon and between the ridges of the 
arbor vita? are numerous racemose glands which are histo- 
logically mere inversions of the mucous membrane. In the 
upper two-thirds of the canal the epithelium on the crests of 
the transverse ridges of the palmse plicatee is ciliated. Else- 
where on the free surface it is goblet-shaped, without cilia. 

i Centralb. f. Gyn., 1893, No. 33. 



30 ESSENTIALS OF OBSTETRICS. 

The gland-cells are cuboidal and non-ciliated. The epi- 
thelium of the lower third of the cervical canal and of the 
entire external surface of the portio vaginalis is squamous, 
like that of the vagina. The secretion of the cervical glands 
is a clear tenacious mucus having an alkaline reaction. 

The muscularis constitutes the greater part of the thick- 
ness of the uterine walls. Its fibre is of the unstriped variety. 
The muscular wall is usually described as consisting of three 
layers ; but this division into strata cannot be made out ex- 
cept during gestation, and even then the layers are not dis- 
tinctly separable. 

The outer layer, which is very thin, consists chiefly of 
longitudinal fibres which are continuous with the muscular 
layers of the Fallopian tubes, the ovarian, round, and utero- 
sacral ligaments. 

The middle layer comprises the bulk of the uterine 
muscle and is a meshwork of interlacing longitudinal and 
circular bundles. 

The inner layer, which is made up of circular bundles is 
extremely thin. It surrounds the orifice of the Fallopian 
tubes and forms a sphincter at the os internum. 

The cervix consists mainly of connective tissue. A well- 
marked band of circular fibres encircles the cervix at the 
vaginal junction. 

The peritoneal coat. The uterus is partially enveloped 
in a transverse fold of the pelvic peritoneum. The latter 
structure invests the upper portion of the uterus, extending 
over the entire length of the organ posteriorly and to the 
isthmus anteriorly. 

The Nulliparous and the Parous Uterus. In the nulliparous 
uterus the corporeal cavity is triangular, the fundus nearly 
flat, the cervix somewhat conical, and the os externum a 
mere dimple. In the parous uterus the cavity is oval, the 



ANATOMY OF FEMALE GENITAL ORGANS. 31 

fundus dome-shaped, the cervix cylindrical, and the os ex- 
ternum a transverse slit, with the lips more or less fissured. 
The differences in weight and in size have already been stated. 

Position of the Uterus. In the upright posture of the 
woman the average normal position of the uterus is such 
that the body lies nearly in a horizontal plane. 

Ligaments of the Uterus, (a.) The broad ligaments. 
The pelvic peritoneum dips down posteriorly into the lesser 
pelvis, is reflected over one inch or more of the upper part 
of the posterior vaginal wall, covers the posterior surface of 
the uterus, and passing over the fundus invests the anterior 
uterine surface to the isthmus ; thence it is again reflected 
upward and over the bladder. The uterus thus lies between 
the layers of a transverse fold of peritoneum, the lateral por- 
tions of which, stretching from the uterus to the sides of 
the pelvis in front of the sacro-iliac joints, form the broad 
ligaments. The two layers of each broad ligament are 
nearly in apposition, except at their junction with the pelvic 
floor and with the pelvic walls. The Fallopian tube is en- 
veloped in a subsidiary fold of peritoneum at the upper mar- 
gin of the broad ligament. The round ligament directly 
underlies the anterior layer. The ovarian ligament runs be- 
tween the two layers. There are also included between the 
two layers important bloodvessels, lymphatics, nerves, smooth 
muscular fibres and connective tissue. 

The infundibulo-pelvic, or ovario-pelvic, ligament is that 
part of the superior border of the broad ligament on each 
side, extending from the Fallopian tube to the pelvic wall. 

(6.) The utero-sacral folds are two semilunar folds of 
peritoneum enclosing unstriped muscular fibres and connec- 
tive tissue, and passing one on each side of the rectum from 
the lower portion of the sides of the uterus to the second 
bone of the sacrum. In the nulliparous woman they spring 



32 ESSENTIALS OF OBSTETRICS. 

from the uterus at the level of the os internum ; in the 
parous, from points somewhat above the os internum. These 
folds are also known as the folds of Douglas, and the space 
between them as Douglas's pouch or cul-de-sac. Luschka 
terms these ligaments the retractors of the uterus. 

(c.) The utero-vesical folds are two folds of peritoneum, 
one on either side of the median line, which extend from 
the uterus to the bladder, forming the lateral borders of 
the utero-vesical space. They contain a few muscular 
fibres. 

(d.) The round ligaments are two slender, flattened mus- 
culo-fibrous cords which spring from the angles of the uterus 
in front of the Fallopian tubes, and pass forward through 
the inguinal canals to blend with the structures at and im- 
mediately below the external ring. They contain unstriped 
muscular fibres. Their length is 10 to 12.5 cm. (4 to 5 
inches). A small artery and a vein pass through each. 

The Arteries. The arteries of the uterus are the two 
uterine, the two ovarian and the two funicular arteries, or 
arteries of the round ligaments. The uterine artery is a 
branch of the internal iliac, the ovarian springs from the 
aorta. They pass to the uterus between the folds of the 
broad ligament on either side. The uterine artery reaches 
the uterus just above the vaginal junction, the ovarian at 
the level of the cornua. The former runs up along the lateral 
border of the uterus to communicate with the ovarian. 

The uterine arteries are remarkable for their free anasto- 
moses and their tortuous course. Arterial tufts are given off 
at the lateral borders of the organ, whose branches form 
spirals within the uterine walls. They end in a meshwork of 
capillaries about the utricular glands. Other branches of the 
uterine arteries anastomose with those from the opposite 
side encircling the uterus. The circular artery surrounds 



ANATOMY OF FEMALE GENITAL ORGANS. 33 



Fig. 




Arteries of the uterus. 



34 ESSENTIALS OF OBSTETRICS. 

the cervix at the isthmus, uniting the uterine arteries of the 
opposite sides with each other. 

The artery of the round ligament, which is a very small 
one, is a branch of the vesical given off at the internal ab- 
dominal ring. It communicates at the cornua with the 
ovarian and the uterine artery. 

The Veins. The uterine plexus of veins lies immedi- 
ately beneath the peritoneal coat of the uterus and extends 
between the folds of the broad ligament. It communicates 
with large sinuses in the middle muscular coat which are 
encircled by muscular bundles. The uterine veins also 
anastomose with the vaginal and the vesical plexuses. Their 
outlet is the hypogastric vein and the pampiniform plexus. 

The Lymphatics. These are very numerous in the body 
of the uterus, and they communicate with the lymph-spaces 
of the mucous membrane and the muscular coat. They 
form an intricate network immediately beneath the perito- 
neal coat of the uterus, and communicate with those of the 
Fallopian tubes. The uterine lymphatics are fully devel- 
oped only during pregnancy. The lymphatics of the body 
of the uterus with those of the Fallopian tubes and the 
ovaries empty into the lumbar glands. A group which fol- 
lows the course of the round ligament ends in the inguinal 
glands. The cervical lymphatics unite with those from the 
upper part of the vagina and empty into the internal iliac 
glands. 

The Nerves. These are derived chiefly from the sympa- 
thetic system, from the inferior hypogastric and spermatic 
plexuses. The uterus also receives filaments from the second, 
third and fourth sacral nerves. The uterine nerves termi- 
nate in part in the nuclei of the muscle-cells. 

The Fallopian Tubes or Oviducts. These are two 
narrow tubes, one running outward from each horn of the 



ANATOMY OF FEMALE GENITAL ORGANS. 35 

uterus and communicating with the uterine cavity. The 
outer portion of each tube takes a tortuous course, partially 
surrounding the ovary. The length of the tube is from 7.5 
to 12.5 cm. (3 to 5 inches), the right a little longer than the 
left. 

Divisions, (a.) The isthmus is the portion of the tube 
next the uterus. It expands gradually as it runs outward 
from 2 mm. (j 1 ^ inch) to 4 mm. ( T 3 g- inch) in diameter. 



Fig. 7. 




Fallopian tube and ovary. 



(b.) The ampulla is the dilated portion of the tube next 
beyond the isthmus, about 1 cm. (J inch) in diameter. The 
fimbriated extremity, pavilion or infundibulum, is the free 
trumpet-shaped end of the tube, the margin of which is 
fringed with a number of processes (four or five) called 



36 



ESSENTIALS OF OBSTETRICS. 



fimbria? . Here the tube expands abruptly to about 2 cm. 
(3J inches) in diameter. 

The fimbria ovariea is a special fimbria, a little larger 
than the others, which is attached to the ovary. 

The ostium uterinum barely admits a bristle, 1 mm. 
(^ inch) in diameter. 

The ostium abdominale, at which the body of the tube 
opens into the pavilion, is of the size of a small goose-quill, 
5 mm. in diameter. 

Structure. Each tube comprises three layers continu- 
ous, respectively, with the corresponding layers of the 
uterus : 

Fig. 8. 




The ovary and oviduct. (The latter opened longitudinally.) 1, 1. Ovary. 2. 
Part of the uterus. 3. Ovarian ligament. 4, 4. Oviduct, its walls opened by a 
longitudinal incision to show the longitudinal folds of its lining membrane. 5, 
5. Pavilion from internal surface. 6, 6. Fimbria attached to the ovary, or tubo- 
ovarian ligament. 7, 7. Longitudinal folds. 8. Internal end of the oviduct. 



1. The outer or peritoneal coat, continuous with the peri- 
toneal fold of the broad ligament. That part of the broad 
ligament between the tube and the ovary is termed the 
mesosalpinx. 

2. The middle or muscular coat, composed of an inner 



ANATOMY OF FEMALE GENITAL ORGANS. 37 

circular and two outer longitudinal layers of unstriped mus- 
cular fibre. The outermost layer, however, is limited to the 
uterine end of the tube. The muscular coat contains a rich 
plexus of bloodvessels. 

3. The inner or mucous coat. Except in the intramural 
portion of the tube, the mucous membrane is disposed in 
longitudinal folds, which become extremely complex in the 
ampulla. There is no distinct submucous layer. It is lined 
with ciliated columnar epithelium and is very vascular. The 
motion of the cilia propels toward the uterus. According 
to Bland Sutton, the mucous membrane of the tubes is pro- 
vided with glands. 

The arteries of the Fallopian tubes are branches of the 
ovarian and the uterine arteries. 

The veins open into the pampiniform or ovarian plexus 
lying between -the folds of the broad ligament below the 
tube. 

The lymphatics unite with those from the body of the 
uterus and from the ovary, and terminate in the lumbar 
glands. 

The nerves are derived from the uterine and ovarian 
plexuses. 

The Ovaries. The ovaries, two in number, correspond 
to the testes of the male. 

Situations. These organs are situated one on each side 
of the uterus 2.5 cm. (1 inch) or more below the level of the 
ilio-pectineal line, and the same distance from the uterus ; 
yet they have great mobility within normal limits. Each 
is set in the posterior fold of the broad ligament, and is con- 
nected with the corresponding horn of the uterus by the 
ovarian ligament. 

Shape. The usual shape of the ovary is a flattened 
ovoid ; its free border is convex ; the anterior edge is nearly 

3 



38 ESSENTIALS OF OBSTETRICS. 

straight. This straight border is the hilum. The ovary is 
thinnest at the hilum, thickest at the convex border. The 
inner end is narrower, pointed, and merges into the ovarian 
ligament ; the outer is more obtuse and bulbous. The shape, 
however, is variable. 

Size. The size is about 3.5 cm. (If inch) in length by 
2 cm. (f inch) in width and 1.2 cm. (J inch) in thickness, 
but is variable. The average normal weight in the nullipara 
is about 6 grammes (85 grains). The size increases during 
menstruation. 

Structure. 1. External. In early age the external 
surface is smooth, like an almond. Later in life, after 
puberty, it gradually becomes uneven, acquiring a wrinkled 
appearance, owing to cicatrices from rupture of Graafian 
follicles. In the young adult subject it has a velvety soft- 
ness and a pinkish or grayish-pearly color. In old age it 
acquires a cartilaginous hardness and a paler color. The 
free surface of the ovary is covered with modified perito- 
neum. Its epithelium is columnar and non-ciliated — the 
germinal epithelium of Waldeyer. 

2. Internal. The stroma is made up of connective tissue 
with some unstriped muscular and elastic fibres. 

The tunica albuginea is a dense layer of stroma imme- 
diately underlying the germinal epithelium of the ovarian 
surface. 

The zona parenchymatosa is the cortical portion of the 
ovary ; it has a grayish color. 

The medullary zone, or zona vasculosa, is the portion 
about the hilum; it is of a reddish color. Here enter the 
bloodvessels, nerves, and lymphatics. 

The ovarian ligament is a muscular band about 0.5 mm. 
(■£- inch) in width, which extends between the folds of the 
broad ligament from the inner end of the ovary to the horn 



ANATOMY OF FEMALE GENITAL ORGANS. 39 



of the uterus, joining it immediately behind and below the 
origin of the Fallopian tube. Its length is about 2.5 cm. 
(1 inch). It is made up of connective tissue and smooth 
muscular fibres, the latter being continuous with the outer 
muscular layers of the uterus. 

The arterial supply of the ovary is from branches of the 
ovarian artery which enter at the hilum. The veins issue 
from the hilum and empty into the pampiniform plexus. 

The lymphatics, with those of the tube and body of the 
uterus, empty into the lumbar glands. 

The nerves are derived from the inferior hypogastric 
plexus and the sacral nerves. 




Section of ovary magnified to show Graafian follicle and ovum. 1. Surface epi- 
thelium. 2. Tunica albuginea. 3, 3. Different parts of stroma. 4. Tunica fibrosa 
of follicle. 5. Tunicae propria. 6, 6. Tunica granulosa. 7. Liquor folliculi. 8. 
Vitelline membrane of ovum. 9. Vitellus. 10. Germinal vesicle. 11. Germinal 
spot. 

Graafian Follicles. The Graafian follicles are the sacs 
in which the ova are developed. The follicles are deyeloped 



40 ESSENTIALS OF OBSTETRICS. 

from the germ epithelium of the ovarian surface, and be- 
come imbedded in the stroma by the outgrowth of connec- 
tive tissue. They are most numerous in the cortical layer. 
Each follicle contains generally but one ovum. The number 
of rudimentary Graafian follicles at birth is 35,000 or more 
in each ovary. At any time during the child-bearing period 
ten or twenty Graafian follicles may be found in different 
stages of development upon the ovarian surface. The size 
of a mature Graafian follicle is ^io *° tV ^ ncn m diameter. 

Structure of a Graafian Follicle. The constituent parts of 
a Graafian follicle are : 1. The theca folliculi ; 2. The tunica 
(membrana) granulosa, a multiple layer of polyhedral epithe- 
lium; 3. The discus proligerus, or germinal eminence, a 
heaped-up mass of cells of the membrana granulosa at one 
side, containing the ovum ; 4. The liquor folliculi, a clear, 
albuminous fluid — paralbumin. 

The Parovarium. The parovarium consists of a series 
of 10 to 20 tubules running between folds of the broad liga- 
ment in a slightly downward direction from the o^ary toward 
the ampulla of the Fallopian tube. It is the remnant of 
the Wolffian body. 



CHAPTER II. 
PHYSIOLOGY OF PREGNANCY. 

PHYSIOLOGY OF THE OVUM. 

OVULATION. 

Ovulation is the process by which the ovum or egg is 
matured and discharged from the ovary. At what intervals 
ovulation occurs in the human subject, and in what relation 
to the menstrual epoch, are not yet fully determined. Gen- 
erally it takes place at about the time of the catamenia. 
Ovulation, however, may occur independently of menstru- 
ation, and menstruation without ovulation. As a rule, but 
a single follicle ruptures at each epoch. Under favorable 
conditions both the ova and the spermatozoa may retain 
their vitality for several days in the female genital tract. 

MENSTRUATION. 

Menstruation is a periodic congestion of the female gen- 
ital organs, attended with a bloody uterine discharge — the 
menses or catamenia. The endometrium undergoes partial 
exfoliation and subsequent renewal. Popular terms for 
menstruation are the monthly sickness, the courses, or 
monthly turns. 

The constituents of the menstrual flow are blood and shreds 
of endometrium, together with uterine and vaginal secre- 



42 ESSENTIALS OF OBSTETRICS. 

tions. The amount is from four to six ounces j the 
length of the catamenial period is from two to seven days ; 
the average duration four days ; the interval between the 
menstrual epochs is generally twenty-eight days. Intervals 
of several days, more or less than the usual length, however, 
are to be considered normal, if constant. The source of the 
bloody discharge is the body of the uterus and probably the 
Fallopian tubes. Menstruation is usually attended with 
some degree of malaise, sacral pain and pelvic tenesmus. 

Puberty is the period of sexual maturity, and is marked 
in the female by the onset of menstruation. 

The age of puberty is usually about the fifteenth or six- 
teenth year. It varies with race, climate and other influ- 
ences, occurring in exceptional instances as early as the 
tenth or as late as the twentieth year of age. It is earlier 
in warm than in cold climates, in the better than in the 
poorer classes, and in city than in country life. At this 
period the girl takes on the physical and mental character- 
istics of womanhood. 

The Menopause. The menopause is the final cessation of 
menstruation and the capacity for child-bearing. Climacteric 
and change of life are synonymous terms for menopause. 
In most women this period begins at the age of forty-six 
years. The change, however, is a gradual one, occupying 
two or three years. Variations of ten years or more on 
either side of this limit are possible. The anatomical 
changes which take place in the sexual ogans are essentially 
the reverse of those which characterize the pubescent period. 
In extreme old age the uterus is reduced to its infantile 
dimensions and the tubes and ovaries are almost obliterated. 
As a rule, the menstrual function continues longest in those 
in whom it begins earliest. In cold climates the fruitful 
period begins late and ends early, and in hot climates it 



PHYSIOLOGY OF PREGNANCY. 43 

begins early and ends early. At the onset of the menopause 
the catamenia recur at irregular intervals, and finally they 
cease altogether. The intervals may be shortened or pro- 
longed. The flow may be scanty or profuse and prolonged. 
Headache, tinnitus aurium, vertigo, hot flashes, palpitation, 
dyspnoea, faintness, pruritus and neuralgias are common 
nervous disturbances of this period. 

Phenomena attending the Rupture of a Graafian 
Follicle. Loops of bloodvessels are projected into the 
cavity of the follicle, and an increase of the fluid contents 
of the sac takes place from the increased vascularity. Ad- 
jacent portions of the ovary, and to a certain extent its 
entire structure, exhibit a similar increase in vascularity. 
The follicle is now apparent as a bright red spot on the 
surface of the ovary. 

The overlying ovarian structure undergoes absorption 
owing to increased pressure of the liquor folliculi. The 
distending follicle finally ruptures and discharges its con- 
tents, an effusion of blood taking place into the follicle after 
rupture. 

The ovum is apparently floated into the pavilion of the 
tube by a stream of serum which is propelled by the cilia of 
the fimbria* ovarica. Its propulsion through the Fallopian 
tube is accomplished partly by ciliary motion, and, in the 
narrower portion of the tube, partly, perhaps, by muscular 
action. Heil thinks other agencies are concerned in the 
migration of the ovum into the oviduct, and believes, as was 
formerly assumed, that the pavilion of the tube grasps the 
ovisac. 1 Rarely, it happens that the ovum migrates across 
the pelvic cavity and into the opposite Fallopian tube. 

The Ovum. The ovum is primarily a nucleated cell 

1 Arch. f. Gyn., 1894, B. xliii. H. 3. 



44 



ESSENTIALS OF OBSTETRICS. 



developed from the germ epithelium which covers the surface 
of the ovary. Its diameter at maturity is t Jq- inch. 

The constituent parts of the ovum are : 

The vitelline membrane ; 

The vitellus or yolk, oleo-albuminous matter, containing 
shining granules; 



Fig. 10. 




Section of nearly mature ovum and part of Graafian follicle, a. Membrana 
granulosa, b. Discus proligerus. c. Vitelline membrane. /. Vitellus. 



The germinal vesicle, which is the nucleus of the cell, 
t ^-q inch in diameter, situated to one side of the yolk near 
its surface; 

The germinal spot, the cell nucleolus, a dark, granular 
spot, about so^o inch in diameter, within the vesicle. 

The female pronucleus. The germinal vesicle approaches 
one pole of the ovum, and two rounded masses, the polar 
globules, are successively extruded from the surface of the 
egg. The office of these bodies is unknown. The remaining 
portion of the germinal vesicle reappears in the centre of the 



PHYSIOLOGY OF PREGNANCY. 



45 



egg, and is now known as the female pronucleus. As will 
be seen presently, the fusion of the female with the male pro- 
nucleus is the essential fact in fecundation. 

The Corpus Luteum. The corpus luteum is the body 
formed in the ovary by the changes which take place in the 
Graafian follicle after rupture. 

The 'corpus luteum of menstruation reaches its full devel- 
opment in from two to four weeks, and it becomes reduced 
to a mere cicatrix in about two months. 



Fig. 11. 




Section of human ovary, showing corpus luteum. 

The corpus luteum of pregnancy grows for six or seven 
weeks, then it remains stationary to the end of the fourth 
month ; from that time it retrogrades slowly till term, and 
becomes a mere cicatrix by the end of a month after child- 
birth. The period of growth, however, and the rapidity of 
decline, are not in all cases the same. 

CONCEPTION— IMPREGNATION. 



Impregnation, or conception, is the fructification of the 
ovum by union with the spermatozoon, the fecundating ele- 

3* 



46 ESSENTIALS OF OBSTETRICS. 

ment of the male. Insemination is the act by which the 
seminal fluid is deposited in the female genital tract. 

The Seminal Fluid. The seminal fluid is a glutinous, 
alkaline, albuminous fluid, of a whitish color, heavier than 
water, and is the combined product of the testicles, the pros- 
tate and Cowper's glands. The quantity ejaculated during 
an orgasm is from one to three drachms. Its chemical con- 
stituents are water, fats, proteids, calcium and sodium chlo- 
rides and phosphates. The proportion of mineral ingredients 
is about 3 per cent. Its microscopic elements are epi- 
thelium, leucocytes, spermatozoa, and crystals of calcium 
phosphate. 

The Spermatozoa. The spermatozoa are bodies of mi- 
croscopic size resembling tadpoles in shape. The parts of 
the spermatozoon are a flattened ovoid head (cell nucleus) 
and a long, thread-like tail. The filiform tail maintains a 
constant vibratile motion, the result of amoeboid movements 
of protoplasm, so long as the spermatozoon retains its fecun- 
dating power. The total length of a spermatozoon is -g-J-g- to 

4 <hr inch - 

Vitality of Spermatozoa. Under favorable conditions the 

spermatozoa, as well as the ovum, live within the genital 

passages of the female for a week or more. In the human 

species they have been found in active motion after eight 

days. 

They are destroyed by extremes of heat or cold. The 
seminal elements of man retain their motility, however, be- 
tween the temperatures of 5° and 116° F. They are de- 
structible by acids, by numerous other chemical agents and 
by desiccation. 

The Migration of Spermatozoa. Under normal conditions 
the male fluid is ejaculated upon and about the cervix. 
Yet the spermatozoa may traverse the entire length of the 



PHYSIOLOGY OF PREGNANCY. 47 

female genital tract by their own powers of locomotion, and 
impregnation may take place in exceptional cases without 
introception of the male organ. Locomotion is accomplished 
by the lashing action of the tail. They move at the rate of 
about an inch in seven and one-half minutes. 

Place, Time and Mode of Impregnation. Impregnation 
is by most authorities thought to take place in the outer 
portion of the Fallopian tube. The usual date of con- 
ception is probably within a week after the cessation of a 
menstrual period. As a rule, the ovum is fecundated by a 
single spermatozoon. The spermatozoon penetrates the egg, 
its tail is absorbed, and its head forms the male pronucleus. 
The male moves toward the female pronucleus and unites 
with it to form the vitelline or segmentation nucleus of the 
fecundated egg. The fructified egg is called the oosperm. 

DEVELOPMENT OF THE IMPREGNATED OVUM. 

The egg on leaving the ovary has a diameter of ji^-inch. 
At its escape from the ovary it is partially enveloped in cells 
of the membrana granulosa. During its transit through the 
oviduct it receives an albuminous envelope which supplies 
the first nutriment for its development. On its entrance 
into the uterus it lodges in the folds of the decidua. 

Segmentation. Immediately after the formation of the 
vitelline nucleus the yolk subdivides into two spheres. The 
process of cleavage begins in the nucleus and extends 
throughout the vitelline mass. The two cells thus formed 
lie within the zona pellucida. By the continuance of the 
process of segmentation these cells divide into four and the 
four into eight, and so on until the entire yolk becomes a 
granulated mass. This has received the name of the muri- 
form body. Cleavage taking place through the vitelline 



48 ESSENTIALS OF PREGNANCY. 

nucleus, its ultimate segments form the nuclei of the result- 
ing cells. These cells are of two sizes. The smaller, which 
are the more transparent and are cubical in shape, are the 
epiblastic; the larger, which are polygonal in form, are the 
hypoblastic cells. Segmentation in the human subject prob- 
ably does not occupy more than six days. By the time it 
is complete the ovum has usually reached the cavity of the 
uterus and has grown to a diameter of fa to fa inch. 

The Blastoderm. The epiblastic cells unite to form a 
continuous layer which lines the zona pellucida. This is 
the epiblast or ectoderm. 

By the union of the hypoblastic cells is formed another 
layer, the hypoblast or endoderm. The epiblast and the 
hypoblast are in contact within the area which marks the 
site of the future embryo, elsewhere they are separated by 
fluid. Between these two a third layer, the mesoblast or 
mesoderm, is subsequently formed. This layer, however, is 
limited to that part of the oosperm at which the embryo is to 
be developed. The three layers together constitute the 
blastoderm. The oosperm, now dilated into a vesicle by 
accumulation of fluid in its cavity, is called the blastodermic 
vesicle. 

DEVELOPMENT OF THE EMBRYO. 

From the ectoderm are formed the epidermis, hair, nails 
and the glandular structures of the skin, cerebro-spinal 
nervous system, the organs of special sense, and the chorion, 
amnion and placenta. 

From the mesoderm are developed bone, muscle, connec- 
tive tissue, the heart and bloodvessels, peritoneum, pleurae, 
spleen and the genito-urinary organs. 

From the endoderm are formed the lungs, liver, stomach, 



PHYSIOLOGY OF PREGNANCY. 49 

pancreas, intestines, the epithelium of the digestive tract 
and the allantois. 

The area germinativa, or embryonic spot, appears upon 
the blastoderm as an opaque, oval spot, consisting of an 
aggregation of hypoblastic cells on the inner surface of the 
membrane. In the long axis of this area the embryo is 
developed. 

The area pellucida is a clear, oval space, which soon ap- 
pears in the centre of the area germinativa. 

The primitive trace is a longitudinal streak which appears 
in the median section of the area pellucida in consequence 
of a thickening of the blastodermic layers in this part. 

The medullary canal. Two longitudinal folds spring up, 
one on either side of the primitive trace, and by the end of 
the first month of intrauterine life they have arched over 
and united to form the medullary or cerebro-spinal canal. 

Somatopleure and Splanchnopleure. The mesoblast on 
either side of the median-axial line splits into two lamina, 
the outer one of which unites with the epiblast to form the 
somatopleure or primitive body-wall, and the inner one 
with the hypoblast to form the primitive splanchnopleure or 
rudimentary digestive tract. The space between the somato- 
pleure and the splanchnopleure is the primitive body-cavity. 
This is ultimately divided into pleural, pericardial and peri- 
toneal cavities. 

THE FCETAL MEMBRANES. 

The Amnion. This is the innermost of the foetal en- 
velopes. At about the time when the embryo begins to 
take shape folds of the somatopleure spring up around 
the edges of the embryo. (Figs. 12 and 13.) This mem- 
branous ridge grows until its edges meet over the back of 



50 ESSENTIALS OF OBSTETRICS. 

the embryo. The surfaces brought into contact become 
fused together. (Fig. 14.) The pouch thus formed is the 
amnion. Within it is the embryo. It is gradually expanded 
by accumulation of its fluid contents, the liquor amnii. 

Fig. 12. 




a, a. Beginning development of amnion, z. Zona pellucida or vitelline 
membrane, s. Epiblast. m. Hypoblast, u. Umbilical vesicle. 

The outer layer of the folds, which is termed the false 
amnion, recedes to the vitelline membrane. 

The liquor amnii is an alkaline liquid having a specific 
gravity of 1002 to 1015. In the earlier months of preg- 
nancy it is clear and transparent ; in the later months it 
becomes turbid, owing to the presence of skin epithelium, 
lanugo and particles of vernix caseosa. At the time of 
labor it sometimes has a dark greenish-brown color, from 
the presence of meconium. In the first half of pregnancy 
it is contributed from a system of capillary bloodvessels of 
the placenta immediately underlying the amnion. In the 
later months it consists partly of foetal urine. 

Its principal constituents in the last weeks of pregnancy 
are water, a trace of albumin, mucin, saline matter, creatin, 
creatinin, urea, epithelium. The normal quantity at term is 
from one to two pints. 

Uses. During gestation it not only permits active foetal 
movements, but it protects both the uterus and the foetus 



PHYSIOLOGY OF PREGNANCY. 



51 



by equal distribution of the intrauterine pressure. Swal- 
lowed by the foetus, and, in the early months of gestation, 
absorbed through the skin of the embryo, it supplies water 
to the foetal tissues. During parturition, so long as the 
membranes are unbroken, it helps to dilate the cervix by 
hydrostatic pressure. 



Fig. 13. 




a\ a 
a, a. Development of amnion at a more advanced stage, p. Allantois. 

The Allantois. The allantois is a diverticulum devel- 
oped from the posterior part of the endoderm or the intes- 
tinal canal at about the time the amniotic folds are formed. 
It is projected to the outer envelope of the ovum, which 
now consists of the vitelline membrane and the false amnion 
joined in one. It spreads until, by the end of the third 
week, it lines the entire external envelope of the ovum as a 
flattened sac. (Figs. 13, 14 and 15.) 

Its office is to carry bloodvessels from the embryo to that 
portion of the outer envelope at which the placenta is to be 
developed, the chorion frondosum. The allantoic arteries 
are two in number ; after the complete development of the 
umbilical cord they are called the umbilical arteries. 

The stem of the allantois ultimately dwindles to a mere 
cord, which is termed the umbilical communication : this is 
the rudimentary umbilical cord. 



52 



ESSENTIALS OF OBSTETRICS. 



The Chorion. This structure consists mainly of a layer 
of connective tissue and one of pavement epithelium. The 
former becomes fibrous in the later months of pregnancy. 

In the second week of its development the ovum becomes 
invested with villosities which spring from its outer cover- 
ing, the vitelline membrane. This envelope, with its villi, 
is the primitive chorion. The permanent chorion is formed 
by fusion of the allantois with the vitelline membrane and 
the false amnion. This structure consists mainly of a layer 
of connective tissue and one of pavement epithelium. The 
former becomes fibrous in the later months of pregnancy. 
The space which persists for the time between the amnion 
and the chorion is filled with a gelatinous material. 



Fig 14. 




Amnion complete. Allantois in contact with external envelope of ovum. 



Union of the Foetal Envelopes. The amniotic sac expands 
until it reaches the chorion and blends with it about the end 
of the second month. At that time the coverings of the 
ovum, from within outward, are the amnion, the chorion, 



PHYSIOLOGY OF PREGNANCY. 



53 



the decidua reflexa, the decidua vera. After the third month 
they become practically a single membrane. The ovum 
loosens its hold upon the uterus at term by the formation of 
a meshy layer in the decidua. 



Fig. 15. 




Allantoic folds united. 4. Umbilical vesicle. 7. Stem of allantois. 



Chorial Villi. Shortly after the fixation of the ovum the 
surface of the chorion, as has already been stated, becomes 
covered throughout with transparent villi. The villi pene- 
trate the decidua, and from it they derive nutrient material 
for the sustenance of the growing ovum. At first they are 
single, but as the ovum develops they elongate and become 
compound. (Fig. 16.) The external surface of the globular 
ovum is, at this period, everywhere " shaggy." (Fig. 15.) 

Bloodvessels of the Villi. At first the villi are not vas- 
cular, but they soon receive bloodvessels from the allantois. 
The capillaries of the chorial villus enter the stem of the 
villus, follow its subdivisions to the end of each rootlet, there 
forming loops, and return to empty into the venous trunks 



54 



ESSENTIALS OF OBSTETRICS. 



of the chorion. The chorial villi are comparable, in struc- 
ture and function, to those of the intestines. 

Chorion Laeve. Toward the end of the second month the 
chorion begins to grow bald over its entire surface, except 
the portion corresponding to the insertion of the foetal blood- 
vessels. Thus by the end of the second month two-thirds 
of the surface of the chorion is smooth, the chorion laeve. 



Fig. 16. 




Compound villus from ovum of three mouths. (Maguified 30 diameters.) 

Chorion Frondosum. Over the remaining third of the 
chorial surface the villosities grow more profusely than 
before to form a thick, spongy mass of villosities ; this part 
of the chorion is the chorion frondosum. The villi are 
destined to form the foetal portion of the placenta. In the 
placental part of the chorion the development of the vessels 
keeps pace with that of the villosities ; elsewhere the 
capillaries shrink with the atrophy of their villi. 

After full development of the placenta the non-placental 



PHYSIOLOGY OF PREGNANCY. 



55 



portion of the chorion, the chorion lseve, serves only for 
protection. 

The Deciduae. With the fixation of the impregnated 
ovum upon the uterine mucous membrane, the latter struc- 
ture undergoes important alterations. It becomes increased 
in vascularity and in thickness, and a fold of the mucosa 
grows up around the ovum, completely enveloping it. This 
hypertrophied mucous membrane of the uterus is called the 
decidua. That part of the decidua which underlies the ovum 



Fig. 17. 



Fig. 18. 



Fig. 19. 




Decidua with ovum 
lodged in its folds. 



Beginning formation 
of refiexa. 



Refiexa completely envel- 
oping the ovum. 



where the placenta is subsequently to be developed is the 
decidua serotina or placental decidua. The rest of the 
uterine mucous lining is the decidua vera or uterine de- 
cidua. (Fig. 17.) The reflected portion which envelops 
the ovum is termed the decidua refiexa or circumflexa, the 
ovular or epichorial decidua. (Figs. 18 and 19.) The 
space intervening between the refiexa and the vera is filled 
with thick, viscid mucus. The refiexa grows with the ovum 
and comes in contact with the vera by the end of the third 
month, uniting with it. The cavity of the uterus is from 



56 ESSENTIALS OF OBSTETRICS. 

this time completely filled by the ovum and its coverings. 
Except at the placental site, the deciduse undergo atrophy 
and are reduced to a single thin membrane by the close of 
the first trimester ; the decidua reflex a disappears entirely 
after the seventh month. 

The Placenta. The placenta, or after-birth, when fully 
developed is a mass of spongy consistence and lenticular 

Fig. 20. 




Foetal surface of placenta. 

shape, measuring from 18 to 20 cm. (7 to 8 inches) in 
diameter and about 2.5 cm. (1 inch) in thickness at the 
insertion of the cord. Its outline is sometimes round, most 
frequently oval. Its usual weight is 454 grms. (1 pound). 
The size of the placenta, however, usually varies with that 
of the child. 



PHYSIOLOGY OF PREGNANCY. 



57 



The foetal surface is a smooth, somewhat concave surface 
of amniotic membrane. The insertion of the umbilical cord 
is most frequently central or nearly so ; sometimes it is ec- 
centric or even marginal. The larger ramifications of the 
placental vessels are visible beneath the foetal membranes. 
(Fig. 20.) 

Fig. 21. 




Maternal surface of placenta. 



The maternal surface is brownish-red, slightly convex and 
rough, presenting divisions into irregular lobes or cotyledons 
from 1 to 4 cm. (J to 1J inches) in diameter, and sixteen to 
twenty in number. These lobes are separated by mem- 



58 ESSENTIALS OF OBSTETRICS. 

branous septa which penetrate the substance of the placenta 
to the foetal surface. The maternal surface is covered with 
the outer layer of the serotina. 

The 'placental seat is normally the upper segment of the 
uterus. It is found on the anterior or the posterior wall with 
nearly equal frequency. It may be situated, however, on 
any portion of the walls of the body of the uterus. 

Development. The formation of the placenta begins 
in the second month of pregnancy. Its limits are distinctly 
defined by the end of the third ; its characteristic form and 
structure are complete by the end of the fourth month. 
The chorionic villi are projected into the interglandular 
portions of the endometrium and ramify to form dendritic 
tufts. The walls of the crypts into which the villi dip are 
lined with epithelium and are extremely vascular. The capil- 
laries around the crypts become enlarged and inosculated till 
every loop of the foetal villi is surrounded by a meshwork 
of dilated maternal capillaries. The latter enlarge, obliter- 
ate the interspaces, and coalesce into lakes of blood. These 
blood-spaces are in free communication with the uterine 
sinuses. 

Structure. The placenta is made up essentially of 
foetal and maternal bloodvessels. The vascular foetal tufts, 
sixteen to twenty in number, are suspended, as it were, in 
lakes of maternal blood. The latter are fed by the curl- 
ing arteries of the uterus. The maternal blood returns 
from the spaces between the foetal tufts by the coronary 
vein at the margin of the placenta and by sinuses in the 
septa between the cotyledons. The foetal and maternal 
circulations have no direct communication with each other. 
(Plate I.) 

Function. The placenta is at once the nutritive, the 
respiratory, and the excretory organ of the foetus. The 




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PLATE II, 




Evolution of the Placenta and of the Umbilical Cord. 
( From Sappey. ) 



1, 1. Embryo. 

2, 2, 2. Amnion. 

3, 3, 3. Cavity of Amnion. 

4, 4. Digestive Canal. 

5, 5. Pedicle of the Umbilical Vesicle. 

6, Umbilical Vesicle. 



7, 7. Allantoic! Vessels. 

8, Pedicle of the Allantois. 

9, 9, 9. Chorial Villi beginning to atrophy 

10, 10, Villi in relation with the utero-placental 

decidna, which hypertrophy. 



PHYSIOLOGY OF PREGNANCY. 59 

interchange between the foetal and maternal circulation 
takes place by osmose through the walls of the foetal villi. 

The Umbilical Cord. The umbilical cord is the pedi- 
cle which, during gestation, connects the foetus with the 
placenta. It is developed from the stalk of the allantois. 
Its foetal insertion is at the umbilicus ; the placental is 
generally nearly central. (Plate II.) 

The usual length of the cord varies from 7 to 60 inches. 
Greater variations are exceptionally observed. The average 
length is 20 inches. Its diameter is about that of the little 
finger of the adult. The tensile strength, at term, varies 
from five to twelve pounds. 

Structure. The cord contains the remnants of the 
vitelline duct and the umbilical vesicle and the umbilical 
vessels imbedded in a jelly-like connective tissue, the jelly 
of Wharton. It is invested with a sheath derived from the 
primitive somatopleure. The covering, though resembling 
amnion, is not a process of that structure, as usually assumed. 

Bloodvessels. Primarily it has two arteries and two 
veins ; subsequently one of the veins disappears. Excep- 
tionally there is but one artery. The walls of the arteries 
are but little thicker than those of the veins. The vessels 
of the cord are arranged in spirals, the vein appearing to be 
wound around the arteries. According to recent observa- 
tions nutritive capillaries, and also nerves and lymphatics, 
are to be found in the cord. 

Rate of Development of the Embryo and Foetus. 

First Month. 1 The ovum is of the size of a pigeon's 
egg ; its diameter is 2 cm. (f inch). Chorionic villi are 
present over its entire surface. The length of the embryo 

1 Lunar month. 



60 ESSENTIALS OF OBSTETRICS. 

is nearly 1 cm. (J inch) ; its weight about 1 gramme (15.43 
grains). The first rudiments of foetal structure are discern- 
ible. The heart, kidneys, liver, extremities, and the eyes, 
the oral and anal orifices begin to be formed. The nose 
and mouth are one cavity. The heart begins to beat at 
the third week. The abdomen is not fully closed. The 
spinal canal closes. The members are indicated by 
papillae. 

Second Month. The ovum is of the size of a hen's egg, 
6.5 cm. (2J inches) in diameter; the length of the embryo 
is a little more than 3 cm. (1J inch); the average weight, 20 
grammes (308 grains). Rudimentary vertebrae appear. The 
frontal unite with the superior maxillary processes. Centres 
of ossification are present in the inferior maxillary bone, the 
clavicle and the sides and bodies of the vertebrae. The 
visceral arches are closed, or nearly so. The eyes, nose, 
and ears begin to take form. The mouth and nose are 
separate cavities. Rudiments of hands and feet appear, but 
the fingers and toes are webbed. The umbilical vesicle has 
disappeared. The umbilical cord is about 2.5 cm. (1 inch) 
in length. Sexual organs are apparent. 

Third Month. The ovum is of the size of a goose's egg ; 
its diameter is 10 cm. (4 inches) ; the embryo is about 8 cm. 
(3 J inches) in length ; its weight 120 grammes (4 \ ounces). 
The product of conception now, for the first time, fills the 
entire cavity of the uterus. The placenta is nearly com- 
plete ; the villi have atrophied over two-thirds of the chorion. 
The umbilical cord is 7cm. (2} inches) in length, and its vessels 
begin to be twisted. The external parts of the embryo are 
distinctly formed. Ossific centres are apparent in most of 
the bones. The fingers are separated, also the toes. Rudi- 
mentary finger- and toe-nails are present. The cavities are 
wholly closed. Sex is determinable by the presence or ab- 



PHYSIOLOGY OF PREGNANCY. 61 

sence of a uterus. Active foetal movements begin in the 
latter part of this month. 

Fourth Month. The length of the foetus is 12.5 cm. (5 
inches); its average weight is about 235 grammes (8 ounces). 
Ossification is established in the frontal and occipital bones. 
The sex is distinctly defined. Lanugo appears. Meconium 
is present. The placenta is now complete. 

Fifth Month. The length of the foetus is 24 cm. (9J 
inches) ; its average weight 500 grammes (17 ounces). The 
cord is about 30 cm. (1 foot) in length. Its point of inser- 
tion, which till the fourth month is still at the symphysis, 
now begins to depart from it. The eyelids commence to open. 
Beginning ossification is apparent in the ischium. Develop- 
ment of hair and nails begins. Vernix caseosa first makes 
its appearance. Heart-sounds are audible. 

Sixth Month. The length of the foetus is 30 cm. (12 
inches) ; its weight is about 1000 grammes (2 pounds and 3 
ounces). The umbilical cord is 35 cm. (14 inches) in length. 
Ossification in the pubic bones begins. 

Seventh Month. The length of the foetus is 35 cm. 
(14 inches) ; it weighs 1500 grammes (3J pounds). The 
pupillary membrane is disappearing. In boys the testicles 
have descended into the scrotum — at least the left one. The 
average length of the cord is 42 cm. (16J inches). Ossifi- 
cation commences in the astragalus. The foetus is viable, 
but its viability is yet feeble. 

Eighth Month. The length of the foetus is 40.5 cm. 
(16 inches) ; its average weight is 2000 grammes (4 pounds, 
6 ounces). The nails are fully developed, but do not project 
beyond the tips of the fingers. A child born at this stage 
of development is viable. Lanugo commences to disappear 
from the face. 

Ninth Month. The length of the foetus is 43 cm. (17 

4 



62 ESSENTIALS OF OBSTETRICS. 

inches). The head diameters are 12 mm. to 16 mm. (J to § 
inch) less than at term ; the average weight is about 2721 
grammes (6 pounds) ; an ossific nucleus first appears in the 
lower femoral epiphysis. Lanugo is disappearing from the 
body. 

Tenth Month. Signs of Maturity. Measurements : 
length 45 to 50 cm. (18 to 20 inches) ; suboccipito-breg- 
matic circumference 33 cm. (13 inches) ; length of foot 8 cm. 
(3J inches). The weight is 3175 to 3288 grammes (7 to 7J 
pounds). The eyes are usually open. The face and body are 
plump. The child suckles and cries lustily. Lanugo is almost 
wholly absent from the body. Vernix caseosa, as a rule, is 
present only on the child's back and on the flexor surfaces of 
the limbs. The finger-nails overreach the finger-tips, the toe- 
nails extend to the end of the bed of the nail. The carti- 
lages of the ear and of the nose have become firm. The 
cranial bones are hard, and the sutures and fontanelles small. 
Centres of ossification are well developed in the lower epiph- 
yses of the femurs and in the astragalus : they are begin- 
ning to appear in the upper epiphysis of the tibia and in the 
cuboid bone. (Plate III.) 

FCETAL CIRCULATION. 

The peculiarity of the foetal circulation arises chiefly from 
the fact that pulmonary respiration is in abeyance during 
intrauterine life, the respiratory blood-changes being accom- 
plished in the placenta. Only so much blood goes to the 
lungs as is needed for their nutrition. From the placenta 
the blood passes to the umbilical vein. A part goes directly 
to the ascending cava by the ductus venosus, and a part 
reaches it indirectly through the liver and the hepatic vein. 
Together with the blood from the lower extremities it then 
goes to the right auricle, and thence is deflected through 



PLATE III. 




The Mature Ovum. (After Runge. ) 



A. Uterine Wall. 

B. Placenta. 

C. Umbilical Cord. 

D. Decidua. 



E. Chorion. 

F. Amnion. 

G. Foetus. 

H. Amnial liquor. 



PHYSIOLOGY OF PREGNANCY. 



63 



the foramen ovale into the left auricle by the Eustachian 
valve, whence it passes through the left ventricle and into 
the aorta. The larger part goes to the arms and the head. 




'Pulmonary Art. 
Left Auricle 
Left Auric. - Vent. 
Operang. 



Ductus Venosus. 



Internal Iliac Arteries. 

Diagram of the foetal circulation. (Flint.) 

Returning by the descending cava to the right auricle it 
goes to the right ventricle, a very small part passing to the 
lungs by the pulmonary artery, the larger part reaching the 



64 



ESSENTIALS OF OBSTETRICS. 



aorta through the ductus arteriosus ; a small portion of this 
mixed blood goes to the lower extremities, the greater part 
being returned again to the placenta by the hypogastric 
arteries. 

EFFECTS OF PREGNANCY ON THE MATERNAL 
ORGANISM. 

Changes in the Uterus. Naturally the first effects of 
pregnancy are to be found in the uterus. The most notable 
clinically are the alterations in the size, shape, and structure 
of the uterus. 

Size. The growth of the uterus begins immediately on 
fixation of the ovum, and is continuous with its growth. 

Fig. 23. 




Size of uterus at different periods of pregnancy. 

In the first two months its development is chiefly in the 
lateral and antero-posterior directions. Subsequently the 



PHYSIOLOGY OF PREGNANCY. 65 

growth is nearly symmetrical. It is mainly due to hyper- 
trophy and to hyperplasia of its muscular fibres. In the 
later months the enlargement is in part by dilatation. 

The thickness of the uterine walls at term is between 4 and 
6 mm. (i and J inch). The internal surface is expanded 
between conception and full term from 32 or 39 square 
cm. (5 or 6 inches), to 2256 square cm. (350 square inches). 
The cubic capacity of the uterus is enlarged more than five 
hundred times, to 4000 c.c. or more. The weight increases 
from 43 grammes (1J ounce) in the pre-gravid state, to 904 
to 1133 grammes (2 to 2J pounds) at term. 



Dimensions of the Gravid Utei 


^US. 


Stage of gestation. 


Total length. 


Width. 


12 weeks . 


. 12.5 cm. (5 in.) 


10 cm. (4 in.) 


16 weeks . 


. 15 " (6 " ) 


12.5 " (5 " ) 


20 weeks . 


. 17.5 " (7 " ) 


15 " (6 " ) 


24 weeks . 


. 21.5 " (8Y 2 " ) 


16.5 " (6% " ) 


28 weeks . 


. 25 " (10 " 


17.5 " (7 " ) 


32 weeks . 


. 29 '• (UV 2 " ) 


20 '• (8 " ) 


36 weeks . 


. 33 " (13 " ) 


22.5 " (9 " ) 


40 weeks . 


. 35.5 " (14 " ) 


25 " (10 " ) 



Shape. In the first three months the shape of the uterus 
is irregularly pyriform ; in the second, the body of the uterus 
is a flattened spheroid, its antero-posterior diameter being 
the smallest; in the last it is generally egg-shaped, the 
fundal being the larger end. Yet the form of the uterus in 
the later months is not altogether constant. 

Structure. The changes which take place in the mu- 
cosa have already been described. The muscular fibres 
grow 7 to 11 times in length, 2 to 5 times in thickness ; 
there is also some hyperplasia of muscular tissue. At the 
internal os there is a preponderance of circular fibres in all 
the layers. The peritoneal coat develops in proportion to 
the increasing size of the uterus. 

The arteries increase in number, length and calibre. By 



66 ESSENTIALS OF OBSTETRICS. 

the later months of pregnancy the ovarian arteries attain 
the size of goose-quills, and the uterine arteries are some- 
what larger still. The size of the lateral branches, which 
connect the ovarian and the uterine arteries on each side, 
exceeds that of the radial artery. The uterine venous plexus 
develops into a system of huge sinuses in the middle coat 
of the muscularis, and in the subplacental portion of the 
inner coat. Some of these vessels attain a diameter of 12 
mm. (J inch). The ovarian and uterine veins are propor- 
tionately enlarged. The lymph-tubes expand to the size 
of goose-quills and the lymph-spaces are expanded. Hyper- 
trophy of the nervous structures keeps pace with the general 
uterine development. 

Changes in the Cervix Uteri. Size. The apparent 
shortening of the cervix during pregnancy is due partly to 
softening and partly to swelling of the vaginal mucosa and 
the loose cellular tissue about the cervix at the vaginal junc- 
tion. The cervical enlargement is partly hypertrophic, but is 
mainly due to loosening of its structure in consequence of 
serous infiltration ; it is progressive to about the end of the 
eighth month. 

Structure. Softening extends progressively from the 
lower border upward ; it involves the entire cervix by the 
end of the eighth month. By this time generally the cer- 
vical canal has become sufficiently expanded in multipara 
to admit the finger, and the head of the child may be 
felt through the membranes. In women pregnant for the 
first time the os externum is seldom as large as the finger, 
even in the later weeks of gestation. 

Changes in other Pelvic Structures. The uterine 
peritoneum is developed by tissue-growth proportionately 
to the development of the uterus itself. 

The broad ligaments adapt themselves to the expansion 



PHYSIOLOGY OF PREGNANCY. 67 

of the uterus partly by the separation of their layers and 
partly by growth in the number and size of their tissue- 
elements. 

The ovaries and the Fallopian tubes lie in contact with 
the sides of the uterus by the time it rises out of the lesser 
pelvis. 

The vagina undergoes hypertrophy during pregnancy. 
The width and length of its walls are increased and it be- 
comes more vascular. 

General Changes. The Heart. According to most 
authorities there is a physiological hypertrophy of the left 
ventricle of the heart during gestation, which is designed to 
meet the increased resistance in the systemic circulation 
brought about by the superadded utero-placental circulation. 
The pulse-rate is slightly accelerated. 

The Blood. The total volume of blood is increased in 
the latter half of pregnancy. There are an increase in the 
proportion of white globules and a diminution in that of the 
red corpuscles and albumin. In the later months there is 
more fibrin. The proportion of water is normally little 
greater than in the non-gravid state. 

The Nervous System. In most gravida? there is a marked 
increase in the irritability of the nervous system. Psychic 
disturbances, neuralgias and other nervous disorders are 
frequently observed. 

The Body-weight. As a rule, a considerable gain in 
body-weight occurs in the later months, due mainly to in- 
creased adipose deposit. 

The Thyroid. The thyroid gland is hypertrophied dur- 
ing pregnancy, and to a certain degree the enlargement 
remains permanent. 

Similar changes also occur in the liver, spleen and, prob- 
ably, in the kidneys. 



68 ESSENTIALS OF OBSTETRICS. 

SIGNS OF PREGNANCY. 

A. HISTORY. 

Suppression of Menses. In a woman of previously regu- 
lar menstrual habit, and in the absence of other appreciable 
causes of amenorrhoea, the arrest of the catamenia is to be 
regarded as strong presumptive evidence of pregnancy. 
Other possible causes of suppression must, however, be ex- 
cluded. These are : 

Anaemia ; Change of climate ; 

Tuberculosis ; Tardy menstruation ; 

Syphilis ; The menopause ; 

Chronic nephritis ; Emotional causes. 

Exposure to cold ; 
This sign is not in all cases available for diagnosis. Con- 
ception may take place during the physiological amenor- 
rhoea of lactation or before the menstrual function is estab- 
lished. In a few recorded cases pregnancy has occurred 
after the menopause. On the other hand, periodical hemor- 
rhages simulating menstruation are sometimes observed in 
the early months of pregnancy. The bleeding in such 
cases generally proceeds from polypi or other lesions of the 
cervix, from chronic decidual endometritis or from placenta 
praevia, and its occurrence at the end of the menstrual 
month results from the influence of the menstrual molimen. 
Usually it may be distinguished from menstruation by the 
irregularity in the amount and duration of the flow. The 
typical menstrual discharge begins and ends gradually, and 
in the intervening time is nearly constant in quantity. The 
usual length of the menstrual period is four or five days. 
Bleeding from other causes seldom presents these charac- 
teristics. 



PHYSIOLOGY OF PREGNANCY. 69 

Nausea is present for a time in the vast majority of preg- 
nancies. Usually it begins about the end of the first month 1 
and ceases by the end of the third, when the uterus rises 
out of the true pelvis. It may subside earlier or last 
longer ; in exceptional instances no nausea is experienced 
during the entire period of pregnancy. 

Generally it is a morning sickness. Sometimes it persists 
throughout the day. Pathological causes, such as chronic 
nephritis and chronic gastric catarrh, may simulate the 
morning sickness of pregnancy, and these must be excluded. 

Ptyalism in greater or less degree frequently accompanies 
the nausea. Excessive salivation is exceptional. 

Hypersecretion of mucus in the mouth and throat during 
the early months of gestation is more common. The 
tenacity of the secretion and the difficulty of expectoration 
have given rise to the term "spitting cotton." 

Certain mammary and abdominal signs may be brought 
out in the history, such as enlargement, a sense of weight, 
fulness and tenderness of the breasts, growth and pigmenta- 
tion of the abdomen and quickening. 



B. PHYSICAL SIGNS. 

1. Mammaey Changes. 

(a.) Increased size and fulness of the glands. The milk- 
glands are enlarged by growth of the acini, swelling of 
the connective tissue and by interlobular deposit of fat. 
Development of the gland must be distinguished from over- 
lying fat. The gland is readily identified on palpation by 
greater density and by its nodular border. 

1 By the term month the calendar month is meant unless otherwise specified. 

4* 



70 ESSENTIALS OF OBSTETRICS. 

The fulness and firmness are not always well marked 
after mid pregnancy. Rarely no material enlargement is 
observed during the entire period of gestation. 

(6.) Primary areolae. Important changes take place in 
the areolae. They become pigmented, elevated and cedem- 
atous. The depth of pigmentation varies according to 
the complexion of the patient. It is faintly developed in 
blondes, well marked in brunettes, and in the negress is 
nearly black. Sometimes it shades into the color of the 
surrounding skin at the upper and outer aspects of the 
areolae toward the end of the second month. The areolae 
acquire a soft, velvety feel and are slightly raised above the 
general level of the skin. The most significant of these 
changes in the primary areolae, however, is the pigmenta- 
tion. (Fig. 24.) 

(c.) Montgomery's follicles are sebaceous follicles of the 
areolae, ten to twenty in number in each, which have become 
hypertrophied during pregnancy. They appear as papu- 
lar elevations within the primary areolae. They are best 
displayed while the skin is held gently on the stretch. 
(Fig. 24.) 

(d.) Enlargement of veins. The superficial veins of the 
breasts become fuller and more prominent. On slightly 
stretching the skin in a good light veins may be seen 
coursing across the areolae. (Fig. 24.) Frequently a vein is 
seen encircling each primary areola at its margin. 

(e.) Milk secretion. Colostrum may be pressed from 
the nipples at the end of the third month. In women who 
have never borne children its presence affords presumptive 
evidence of pregnancy. Yet rarely milk secretion is possi- 
ble in virgins, sometimes even in males. The sign is of no 
value after the first pregnancy, since milk may usually be 
found in the breasts of parous women. 



PHYSIOLOGY OF PREGNANCY. 



71 



To elicit this sign the manipulation should begin over 
the ampullae of the milk-ducts at the base of the nipple. 

(/.) Secondary areolae. These are faintly pigmented 
zones skirting the primary areolae. (Fig. 24.) They are 



Fig. 24. 




The primary and secondary areolae of pregnancy. 



characterized by one or more rows of feebly marked circular 
spots just without the primary areolae. The markings are 
due to non-pigmented sebaceous follicles. In women never 
pregnant before, the secondary areolae are diagnostic when 
well made out. 



72 ESSENTIALS OF OBSTETRICS. 

Date of Appeakance. All the mammary signs, with 
two exceptions, may be looked for by the close of the second 
month. Colostrum is present at the third, and the second- 
ary areolae appear at the fifth month. 

Diagnostic Value. In primigravidse the mammary 
changes usually afford sufficient evidence for, at least, a pre- 
sumptive diagnosis of pregnancy. In women who have 
borne children they are not to be relied on since most of 
them once developed remain more or less permanent. 

The group of mammary signs is rarely complete and those 
present are seldom equally well developed. 

Breast-changes similar to those of pregnancy may result 
from pelvic disease. Pathological conditions of the sexual 
organs which may cause reflex mammary changes must, 
therefore, be excluded. 

2. Abdominal Signs. 

1. Inspection, (a.) Flattening. In the second month 
of gestation the abdomen is slightly flattened ; the uterus 
during this period sinks somewhat lower in the pelvis and 
the hypogastrium is therefore a little less prominent. 

(b.) Enlargement is apparent after the third month, when 
the uterus begins to rise out of the lesser pelvis ; thereafter 
it increases with the growth of the uterus till the middle of 
the ninth month. Within two weeks or more before term 
the uterus usually sinks deeper in the pelvis and the waist- 
line becomes perceptibly smaller. 

(e.) Pigmentation. As a rule pigmentation of the abdo- 
men is limited to a narrow band about 3 mm. (J inch) in 
width extending from the pubes to the umbilicus, sometimes 
to the ensiform. It is present by the end of the second 
month. Pigmentation of the abdomen, like that of the 



PHYSIOLOGY OF PREGNANCY. 73 

breast, varies in depth and extent of surface with the com- 
plexion of the patient. In brunettes a dark circle appears 
around the umbilicus, and pigmented patches are observed 
over other parts of the abdomen. In blondes entire absence 
of pigmentary changes is not infrequent. Deposits of pig- 
ment similar to those of pregnancy are sometimes observed 
in other conditions of health and disease. 

(d.) Umbilical changes. The umbilicus is retracted in 
the first three months and becomes protruded in the last two 
or three. 

(e.) Linese Albicantes, or Striae Gravidarum. These are 
irregular whitish, pinkish or bluish lines developed over 
the lower half of the abdomen during the later months of 
pregnancy. Sometimes they may be observed on the hips 
and thighs. The breasts may present similar markings. 
Usually they are slightly depressed below the general surface 
of the skin. They are due chiefly to partial atrophy of the 
skin from tension ; they appear at about the sixth month. 
Once formed they remain in greater or less degree perma- 
nent. Distention of the abdomen from causes other than 
pregnancy may give rise to similar changes. 

2. Palpation, (a.) Size of the Tumor. The fundus 
uteri lies nearly in the plane of the pelvic brim at the third 
month, reaches the level of the umbilicus by the sixth and 
the ensiform cartilage at the thirty-eighth week. More 
accurate for our purpose than the situation of the fundus 
are the width and length of the uterus. For the uterine 
measurements at different stages of gestation see table on 
page 65. 

(b.) Character of Tumor. The gravid uterus is normally 
a smooth, symmetrical, pyriform or ovoid, fluid tumor. In 
the last trimester, and even earlier, foetal parts may be made 
out by palpation. 



74 ESSENTIALS OF OBSTETRICS. 

(<?.) Intermittent contractions of the uterus may be de- 
tected by the fourth month by abdominal palpation, at an 
earlier period by the bimanual examination. They recur at 
intervals of five or ten minutes ; may be obtained immedi- 
ately by applying the hand cold, or by the use of gentle 
friction over the tumor. They are not abolished by the 
death of the foetus. Haematometra, hydrometra, distended 
bladder and soft fibroids, in all of which contractions may 
occur, must be excluded. 

The value of this sign, to which much importance was 
formerly attached, is vitiated by the fact that contractions 
take place in the non-gravid uterus. 

(d.) Active foetal movements. 1. As an objective sign, 
active movements of the foetus afford conclusive evidence of 
pregnancy. This sign is available by abdominal palpation 
about the fourth month. It is most promptly elicited by 
applying the hand cold to the abdomen or by tossing the 
foetus from side to side. Muscular movements of the foetus 
begin about the tenth week, and may sometimes be detected 
by the bimanual examination as early as the twelfth. In 
hydramnios, and in certain other conditions, detection of 
foetal movements is difficult and often impossible. In oc- 
casional instances they may be absent for a time from no 
apparent cause. 2. As a subjective sign the foetal move- 
ments are not always reliable. In neurotic women they 
may be simulated by intestinal flatus, spasmodic contrac- 
tions of the abdominal muscles and certain other conditions. 

The sensation of foetal movements, as first felt by the 
mother, is termed quickening. The period of quickening 
is usually the end of the fourth month ; yet it varies from 
the twelfth to the twentieth week. Rarely the foetal move- 
ments are not felt by the mother during the entire period 
of pregnancy. 



PHYSIOLOGY OF PREGNANCY. 75 

(e.) Passive fcetal movements ; external ballottement. Ex- 
ternal ballottement is practised by placing the hands over 
the sides of the abdomen with their palmar surfaces facing 
each other and tossing the foetus from hand to hand. Patho- 
logical growths floating in ascitic or other fluid must be 
excluded. 

3. Auscultation, (a.) The funic or umbilical souffle is 
a bruit synchronous with the foetal pulse. It is heard in 
but few cases, and only in the later months. The bruit 
results from partial compression of the cord, impeding the 
blood-current. 

(b.) The uterine souffle is a subdued murmur synchro- 
nous with the mother's pulse. It is usually best heard over 
the lateral aspects of the uterus, especially the left, since 
owing to the usual right torsion of the gravid uterus the left 
border is most readily accessible. It is generally audible 
after the fourth month ; it may sometimes be detected earlier 
by pressing the stethoscope deeply down at the side of the 
uterus. The sound originates in the ascending uterine 
arteries and their branches, and not in the placental sinuses, 
as once believed. It persists after the delivery of the pla- 
centa. In other conditions which give rise to enlargement 
of the uterine arteries and to increased blood-current in 
these vessels a similar souffle may be heard. Thus the 
bruit is commonly present with uterine myomata, chronic 
metritis and even with ovarian cysts. 

(<?.) The choc fcetal is the shock of a foetal movement as 
perceived by the ear on auscultation of the abdomen over 
the uterus. It resembles the effect produced by gently per- 
cussing one hand held flat against the ear with a finger of 
the other hand. The bruit de choc fcetal is a murmur that 
immediately precedes the choc fcetal, owing to displacement 
of liquor amnii by the foetal movements. 



76 ESSENTIALS OF OBSTETRICS. 

(d.) The foetal heart-tones are generally perceptible by 
abdominal auscultation at the fourth or fifth month. By 
vaginal stethoscopy they may sometimes be heard at the 
twelfth week. 

The heart-sounds resemble those of the newborn infant 
heard through several thicknesses of clothing. The rate is 
nearly double that of the maternal pulse, 120 to 150 per 
minute. They are audible over an area of three inches or 
more in diameter. The point of greater intensity is termed 
the focus of auscultation. Usually this nearly overlies the 
lower angle of the left fcetal scapula. Exceptionally there 
may be a second focus, even in single fcetation, due to con- 
duction through some remote point of foetal contact with the 
uterine wall. The heart-sounds may for a time be inaudible, 
owing to dorso- posterior position of the foetus, hydramnios 
or to other causes. Their persistent absence may usually 
be taken as evidence of foetal death. 

Method of Examining. Place the patient in the hori- 
zontal position in a still room. Auscultate by the mediate 
or the immediate method — in other words, with or without 
the stethoscope. Listen over the assumed or previously 
ascertained location of the left fcetal scapula. Eailing there, 
search the entire surface of the tumor. Press the abdominal 
walls firmly against tbe tumor; a continuous solid medium 
favors conduction. In dorso-anterior positions, crowding 
the breech downward in the axis of the foetus helps by arch- 
ing the child's back forward. Failing, try again at intervals 
of a few hours or days. 

A succession of sounds of the characteristic quality and 
rhythm, with a rate double that of the maternal pulse, and 
which can be counted, establishes the diagnosis of pregnancy. 



PHYSIOLOGY OF PREGXAXCY. 77 

3. Pelvic Signs. 

(a.) Purplish color of the vagina (Jac quern in' s sign). The 
vagina takes on a purplish hue. which varies greatly in 
depth in different individuals, and varies in the same indi- 
vidual at different stages of gestation. Usually a venous 
color is faintly developed by the end of the first month. It 
is most constantly observed in the anterior vaginal wall 
immediately below the meatus urethrse. The cause of the 
deepening color is chiefly, at least, hypertrophy of the 
corpus cavernosum of the vestibule and of the vaginal 
venous plexuses. It is to be found in about 80 per cent, of 
cases of pregnancy by the end of the third month. Patho- 
logical congestion must be excluded, since the color in 
pregnancy is not distinguishable from that which is pro- 
duced by pelvic congestion in disease. 

Purplish color of the cervix. A more or less marked 
lividity of the vaginal portion of the cervix may be observed 
almost from the first month after conception. The purplish 
hue of the cervix is not only developed earlier, but it is 
more constantly present than is that of the vagina. Here. 
too, morbid causes must be excluded. 

(b.) Softening of the cervix can usually be made out by 
the touch at the sixth week. At this earlv stage of gesta- 
tion the softened portion is a thin stratum over the lower 
border of the cervix ; it presents the feel of a thin velvety 
layer covering the firm body of the vaginal portion. As 
pregnancy advances the cervical softening progresses from 
below upward and it involves the entire cervix by the end 
of the eighth month. The cervical canal becomes more 
patulous as the softening extends. These changes are 
not always well defined in the early months. Similar 
softening may arise from pathological causes, but it then 



78 ESSENTIALS OF OBSTETRICS. 

lacks the progressive character which belongs to that of 
pregnancy. 

(<?.) Changes in the uterine tumor. The most conclusive 
evidences of pregnancy in the second and third months are 
the alterations in size, shape and consistence of the uterus 
as detected by bimanual examination. The body of the 
uterus grows with the growing ovum, it takes on an irregu- 
larly globular shape and acquires a soft, elastic feel. These 
changes are well marked by the sixth week and they may 
sometimes be recognized at an earlier period. 

Most significant are the softening and enlargement of the 
body of the uterus. The shape is somewhat globular during 
a contraction. When relaxed the body is markedly flattened 
antero-posteriorly, and in the second month much expanded 
laterally. 

Chronic metritis or subinvolution is distinguished from 
utero-gestation by greater density, absence of growth and 
by the history. 

An anteflexed and hyperaemic uterus may resemble the 
gravid tumor in shape and consistence, but it, too, is dis- 
tinguished from pregnancy by the absence of growth. 

A soft submucous fibroid can generally be differentiated 
by the history and by the rate of enlargement. 

Hydrometra and haematometra present the usual char- 
acters of a tense cyst. They are extremely rare. 

Hegar's Sign. One of the most striking peculiarities of 
the uterus in the second month of gestation is the compres- 
sibility of the isthmus uteri, known as Hegar's sign. It is 
especially marked in the median portion of the isthmus, 
which in the non-gravid state is the most dense. 

Method of Examining for Hegar's Sign. The patient 
lies in the lithotomy position. The uterus is depressed by 
the external hand, or is drawn down with a volsella caught 



PHYSIOLOGY OF PREGNANCY. 



79 



in the cervix. The thumb of the other hand is carried into 
the vagina and pressed against the lower uterine segment at 
its junction with the cervix. A finger of the same hand is 
passed into the rectum to a point just above the utero-sacral 
cul-de-sac. The uterine tissues between the thumb and 
finger may be compressed almost to the thinness of a postal 
card. Thinning under pressure to less than a half-centi- 
metre (0.2 inch) establishes the diagnosis of pregnancy. 

Fig. 25. 




Bimanual examination for Hegar's sign ; uterus tilted forward. (Sonntag.) 

The examination may be facilitated by the aid of anaes- 
thesia and by first distending the lower rectum with water. 

The compressibilty of the isthmus may be made out by 
catching it between the index finger of one hand in the an- 
terior, and of the other in the posterior vaginal fornix, the 
uterus being drawn gently down with a volsella. Usually 



80 



ESSENTIALS OF OBSTETRICS. 



it can be done satisfactorily by the ordinary bimanual 
manipulation. 

In examining by conjoined manipulation the uterus may 
be tilted either forward or backward, and the isthmus thus 
be brought between the examining fingers. (Figs. 25 
and 26.) 

Fig. 26. 




Bimanual examination for Hegar's sign • uterus tilted backward. (Sonntag.) 



(d.) Pulsation of the uterine artery is perceptible to the 
touch from the first month of pregnancy. The examining 
finger is held against the vaginal wall at one side of the 
cervix. Pathological growths may give rise to hypertrophy 
of the artery and must be excluded. 

(e.) The temperature of the cervix is from J° to f ° F. 
above that of the vagina or the rectum. This may result ; 
too, from local inflammatory causes, 



PHYSIOLOGY OF PREGNANCY. 81 

( f.) Internal ballottement ; passive foetal movements. Bal- 
lottement is available during the fifth and sixth months. 
Earlier the weight of the foetus is too small, later its 
mobility is generally too limited to permit of ballottement. 

Method. The patient assumes the reclining (half- sitting) 
or the erect posture, the bladder must be empty and the 
clothing loose. Two fingers in the vagina are held against 
the anterior uterine wall above the cervix, the other hand 
steadying the fundus. The foetus tossed upward falls again, 
and taps the finger. 

Distinguish from : anteflexed uterus, a pedunculated 
tumor of the ovary or uterus, internal projections of large 
cysts, a floating kidney, stone in the bladder, pulsation of 
the uterine artery. 

Ballottement may fail from scanty liquor amnii, abdom- 
inal presentation of the foetus, placenta pnevia, multiple 
foetation, etc. 

Summary of Diagnostic Signs. 
The mammary signs collectively in first pregnancies ; 
Detection of foetal parts ; 
Active foetal movements ; 

Changes in the uterine tumor, especially Hegar's sign ; 
Internal ballottement ; 
Foetal heart. 

Abdominal Enlargement erom othee, Causes 

Abdominal enlargement from other causes than gestation 
is distinguished from it by the absence of the diagnostic 
signs of pregnancy, especially those which pertain to the 
uterus. The non-gravid tumors of the abdomen also present 
certain characters of their own by which, as a rule, they 
may be differentiated from gestation. 



82 ESSENTIALS OF OBSTETRICS. 

Hcematometra and Jlydrometra, which may simulate 
pregnancy, have already been alluded to. 

Fat in the abdominal walls may be caught up in folds 
with the hand and moved about over the underlying muscles, 
the patient lying in the dorsal-recumbent position. 

A phantom tumor vanishes under anaesthesia. 

Tympanites usually subsides in the morning, percussion 
is resonant and palpation negative. The abdominal walls 
can be pressed backward against the vertebral column. 
Place the patient in the horizontal position and ask her to 
breathe deeply. Maintain firm pressure with the finger-tips 
on the abdomen. With each expiration the walls sink 
deeper until they touch the vertebral column. 

In ascites, frequently the abdomen is flattened at the um- 
bilicus when the patient lies in the horizontal position. 
Percussion is tympanitic at the summit of the tumor, ex- 
cept in rare instances, in which the mesentery is too short 
to permit floatation of the intestines to the surface of the 
fluid. There is dulness throughout the flanks. 

A fluid wave can be transmitted through all parts of the 
tumor within the limits of the fluid. In pregnancy the 
wave is intercepted by the foetus. The fluid-level changes 
with the posture of the patient. 

In ascites evidence may usually be detected of the patho- 
logical condition which has given rise to the hydroperitoneum. 

Tumors of other organs may be traced to the normal 
location of those organs, and the uterus is readily differenti- 
ated from the tumor. 

In ovarian cystoma, as a rule, there is more pronounced 
fluctuation than in the tumor of pregnancy. There is, too, 
absence of foetal parts, of active foetal movements and of the 
foetal heart. In most cases the uterus may be mapped out 
apart from the tumor. The menses are usually not absent. 



PHYSIOLOGY OF PREGNANCY. 83 

Uterine myomata, when of the submucous variety, are 
distinguished from pregnancy by hemorrhage and generally 
by greater density. 

Subperitoneal myomata are distinguished by the nodular 
character of the tumor. 

The growth in either variety is not so rapid as in gesta- 
tion and the uterus is denser than in pregnancy. Pregnancy 
sometimes coexists with myomata or other pelvic or abdominal 
neoplasms, and then is often extremely difficult of recognition. 

It must be remembered that a uterine bruit like that of 
pregnancy may be heard in a myomatous uterus. 

Multiple Pregnancy. 

Twins occur once in about eighty or ninety pregnancies, 
triplets once in seven or eight thousand. Quadruple and 
even quintuple pregnancies are sometimes met with. A case 
of sextuple pregnancy is recorded. 

Multiple fcetation borders on the pathological. The via- 
bility of the children is lower than in single pregnancy. 
Usually the foetuses are of undersize and of unequal de- 
velopment. Acephalous monstrosity and malpresentation 
are more common than in single pregnancy. The death of 
one or both in utero is not infrequent. Generally twin 
pregnancy is attended with excess of liquor amnii. In two- 
thirds of the cases labor comes on prematurely. 

Origin of Multiple Pregnancy. Multiple pregnancy 
may result from rupture of two or more Graafian follicles at 
the same menstrual period, either in the same or in different 
ovaries, from two ova in one follicle, or from a single ovum 
with a double germ. Children from the same ovum are 
always of the same sex. Hence the members of a double 
monstrosity are alike in sex. 



84 ESSENTIALS OF OBSTETRICS. 

Arrangement of the Membranes and Placentas. In twin 
fetation from separate ovules there are two amnions, two 
chorions and two placentas. The placentas may be sepa- 
rate or fused at their margins. In either case each has an 
independent circulation. 

In twin pregnancy from a single ovum having a double 
germ there is a single chorion containing two amnions ; the 
placenta is single. Rarely two foetuses are found in a 
common sac, the amniotic septum having been destroyed. 

Superfecundation. Superfecundation is a twin pregnancy 
resulting from separate acts of insemination by the same or 
different males of ova expelled at the same period of ovulation. 

Superfoetation. This term was formerly applied to a twin 
pregnancy which was believed to result from the impregna- 
tion of two separate ova thrown off at different periods of 
ovulation. Supposed cases of this character are doubtless 
to be explained as twin pregnancies in which one foetus was 
blighted. 

Duration of Pregnancy. 

The duration of pregnancy is not definitely known, and 
it probably never can be, since the time of fecundation is 
unknown. 

The average period between the beginning of the last 
menstruation and labor is two hundred and eighty days, 
practically ten menstrual months. 

The average interval between the fruitful coitus and the 
birth of the child is two hundred and seventy-three days. 

Variations of twenty days above or below these averages 
are doubtless possible within physiological limits. Much vari- 
ation, however, in the actual period of gestation, with the ex- 
ception of cases in which the pregnancy is cut short by acci- 
dent, is probably extremely rare. The term of pregnancy is 



PHY tlOL : It Y OF PPEGSASC Y. v g 

frequently shortened a :V~ h^ys, or even one or two weeks. 
with d : thing in the character of the labor or the appearance 
of the child which would suggest to the casual >bserver a 
premature birth. So insecure is the attachment of the ovum 
in the last week or two of gestation that labor is :less 

established prematurely in a large proportion of instances. 
On the other hand the pregnancy may appear to be pro- 
longed when in reality the actual term of gestation has not 
exceeded the usual normal limit. It is not infrequently the 
case that concej:: tea, not from the end :: the week 

following the beginning ;: the last menstrual flow as is 
usually assumed, but from some later period in the month. 
An error of two or three week in the count is often thus 
possible. 

Rules and Methods for Predicting the Date of Labor. 

(a.) Naepeh:'s rid :e uine calendar months from 

the beginning of the last menstrual period and add seven 
days. This is a ready method of reckoning approximately 
two hundred and eighty days from the be^innin^r of the last 
menstruation. For predicting :e of labor it is ^rene- 

rally accurate within a week. It is subject) hoi ever, to the 
fallacies already pointed out. 

Reckoning from the date of quickening is uot reliable. 
The period :•: vjiokening is no: jiLstan:. I: varies in 
different individuals, and even in the same individual in 
different pregnancies. Moreover, the observations :: the 
patient in this matter ire :::on fallacious. 

(b.) Mensuration of the uterus is not a wholly re- 
basis for prediction, since the quantity of liquor amnii v: 
in different cases and the sze of the fetus at a given r 
of ges:a:i:n is not constant. 

•5 



8Q ESSENTIALS OF OBSTETRICS. 

Situation of the Fundus. The fundus uteri is in the 
plane of the brim at the third month, at the umbilicus about 
the sixth and reaches the ensiform cartilage at eight and 
one-half months. After lightening it sinks to a little lower 
level. Accuracy here, too, is vitiated by the causes just 
mentioned and also by the fact that the umbilicus is not a 
fixed point. 

(c.) Mensuration of the Fcetus. The total length of the 
foetus is about double that of the foetal ovoid. The latter 
may be measured with sufficient accuracy with a pelvimeter, 
placing one pole in contact with the head through the 
vagina and the other upon the abdomen over the breech, 
or using both poles externally. The rate of foetal develop- 
ment, however, is not uniform ; and, furthermore, extreme 
accuracy of measurement is impossible. Yet this measure- 
ment together with the diameters of the head affords fairly 
reliable data for estimating the stage of pregnancy. 

Length of the Fcetus. 

The approximate lengths of the child in different stages 
of intrauterine development during the later months of ges- 
tation are as follows : 

Sixth calendar month, 30 to 35 cm. (12 to 14 inches). 

Seventh calendar month, 35 to 40 cm. (14 to 16 inches). 

Eighth calendar month, 40 to 45 cm. (16 to 18 inches). 

Ninth calendar month, 45 to 50 cm. (18 to 20 inches). 

HYGIENE OF PREGNANCY. 

The patient should seek the advice of her physician from 
the earlv months of gestation. She should consult him on 
even slight departures from health and especially during 
the later months. 



PHYSIOLOGY OF PREGNANCY. 87 

Hygienic Requirements are : Exercise in the open air an 
hour or two daily, with care to avoid over-exertion and ex- 
haustion ; the avoidance, if possible, of all injurious mental 
influences ; the observance of regular hours for meals ; 
proper quantity and kind of food ; daily bowel movements ; 
eight hours sleep daily ; pure air constantly ; a tepid sponge- 
bath at least twice weekly in winter, once daily in the sum- 
mer months. 

The teeth are especially prone to decay during preg- 
nancy and special care should, therefore, be given them. : 

In case of irritating leucorrhceal secretions a vaginal in- 
jection of a quart of water at a temperature of 98° F., or of 
a borax solution, gss ad Oj, may be used once or twice 
daily. The temperature of the douche should be that of 
the body and the injection must be given with the least 
possible force lest it provoke abortion. 

Clothing. In our climate light flannel underwear is 
essential at all seasons ; the outer clothing must be changed 
to suit changing temperatures. A rational method of dress 
requires no more clothing for indoor use in the winter months 
than would be needed at the corresponding temperature in 
the summer season. For outdoor use extra wraps are called 
for according to the degree of exposure to cold. 

The clothing must not be tight, especially about the 
breasts and abdomen, and the heavier garments ought to be 
suspended from the shoulders. 

Care of the Nipples. It is a useful practice to cleanse 
the nipples daily with a borax solution, 5ss ad Oj, during 
the last two months of pregnancy. They may be anointed 
with fresh cacao butter after cleansing, and if they are 
small or sunken the patient should be taught to draw 
them out with the thumb and fingers. Astringent applica- 
tions such as are frequently employed with a view to hard- 



88 ESSENTIALS OF OBSTETRICS. 

ening the nipples doubtless tend rather to promote cracking 
during lactation than to prevent it. The better practice is 
to keep them supple by the use of inunctions. The manip- 
ulation referred to not only helps to develop the nipples 
when this is required but it has the further effect of inuring 
them to nursing. 

The Urine. The urine should be examined chemically 
and microscopically once a week during the last two months, 
oftener in case of suspicion of nephritis or of renal insuffi- 
ciency. An occasional examination should be made at earlier 
periods. 

Quantitative tests for urea afford the best evidence of the 
functional activity of the kidneys. In all observations of 
the urinary excretion the specific gravity and the quantity 
passed daily are essential as indicating the extent to which 
toxic material is being eliminated. The average normal 
quantity of urea daily is about 33 grammes (500 grains) ; 
the total solids daily about 66 grammes (1000 grains). The 
total solids may be roughly estimated by multiplying the 
last two figures in the number indicatiug the specific gravity 
by the number of ounces of urine and the product by 1.10. 
For the estimation of urea Prof. Bartley's method is recom- 
mended. 1 

When the urine is scanty the ingestion of a larger quan- 
tity of water is indicated. 

Marital Relations. Marital relations are to be restricted, 
particularly at the menstrual dates. Violation of this rule 
is a common cause of abortion and of premature labor. The 
nausea of pregnancy is often aggravated by this cause. 

1 Medical Chemistry, p. 689. 



CHAPTER III. 
PHYSIOLOGY OF LABOR. 

I. THE MECHANICAL FACTORS OF LABOR. 

Three factors are concerned in the mechanism of child- 
birth, the powers, the passages and the passenger. 

1. The Expelling Powers. 

The expelling powers are : 

1. The muscular action of the uterus. This is involun- 
tary, the motor apparatus of the uterus being chiefly con- 
trolled by the sympathetic nervous system. The uterine 
contraction is peristaltic, yet practically simultaneous; it 
begins at the fundus probably. 

2. The action of the abdominal muscles, which is partly 
voluntary, partly a reflex involuntary contraction. 

In the expulsive stage of labor the contractions of the 
abdominal muscles are usually brought into play indepen- 
dently of volition. Their force may generally be augmented 
by voluntary effort. They have the effect to increase the 
intra-abdominal pressure and thus to reinforce the expulsive 
action of the uterus. 

The chief expellent force is the contraction of the uterus. 
Contractions of the muscular elements of the round and of 
the broad ligaments take place at the same time with the 
uterine contraction. They help to steady the uterus in the 
axis of the pelvis. 



90 ESSENTIALS OF OBSTETRICS. 

The power of the uterine contraction reinforced by that 
of the abdominal muscles according to Duncan is 50 to 80 
pounds; according to Schatz it is from 17 to 55 pounds. 

2. The Passages. 

The passages include : 1. The hard parts of the bony 
pelvis ; 2. The soft parts, consisting of the uterus, the pelvic 
floor and the structures which line the osseous portion of 
the birth- canal. 

Obstetric Anatomy of the Bony Pelvis. 

The Pelvis. The pelvis is a strong, bony basin, whose 
cavity is the most important portion of the parturient tract. 

The constituent parts of the bony pelvis are the two ossa 
innominata, the sacrum and the coccyx. 

The joints are the symphysis pubis, the sacro iliac joints 
and the sacro-coccygeal joint. A slight mobility of the pubic 
and the sacro-iliac joints is usually present in the later 
months of gestation. The capacity of the pelvis is thus a 
little larger than in the non-gravid state. 

Extension of the thighs tilts the upper end of the sacrum 
backward and favors the entrance of the head into the pelvic 
brim. The escape of the head from the pelvis at a later 
stage of the labor is promoted by flexion of the thighs upon 
the abdomen, which rotates the lower end of the sacrum 
backward. 

Recession of the coccyx to the extent of 12 mm. to 25 mm. 
(J to 1 inch) occurs during the expulsion of the fcetal head 
from the outlet. 

The false pelvis or greater pelvis is that portion of the 
pelvis above the ilio-pectineal line. It forms with the lower 



PHYSIOLOGY OF LABOR. 



91 



part of the abdominal wall a funnel-shaped approach to the 
true pelvis. 

The true pelvis or lesser pelvis is the part of the pelvis 
below the ilio-pectineal line. It is with this that obstetric 
questions are mainly concerned. 

The brim, inlet, superior strait, margin or isthmus of the 
pelvis is located by the pectineal line and the upper margin 
of the sacrum. Usually it is approximately heart-shaped. 
Sometimes it is oval or nearly round. 



Fio. 27. 




Brim of pelvis. 1. True conjugate. 2. Transverse diameter. 3. Oblique 
diameter. 



Obstetric landmarks at the brim are : 1. The sacral pro- 
montory or sacro-vertebral angle ; 2. The sacro-iliac joints ; 
3. The ilio-pectineal eminences, which are situated at the 
ilio-pubic joint, on the pubic bone ; 4. The symphysis 
pubis. 

The outlet of the pelvis, or inferior strait, is lozenge- 
shaped, and is located by the tip of the coccyx, the subpubic 
arch and the ischial tuberosities. It is made up of two 
obtuse-angled triangles, whose common base is a line joining 



92 ESSENTIALS OF OBSTETRICS. 

the ischial tuberosities ; the apex of the one is the summit 
of the subpubic arch ; the apex of the other is the tip of 
the coccyx. 

Fig. 28. 



Outlet of pelvis. 

Obstetric landmarks at the outlet are : 1. The tip of the 
coccyx ; 2. The subpubic arch, formed by the descend- 
ing rami of the pubic bones ; 3. The ischial tuberosities ; 
4. The ischial spines ; 5. The greater and the lesser 
sacro-sciatic ligaments which help to supplement the bony 
canal. 

The greater sacro-sciatic ligaments spring from the pos- 
terior inferior spines of the ilium and from the sides of the 
sacrum and the coccyx and are inserted into the inner sur- 
faces of the ischial tuberosities. 

The lesser sacro-sciatic ligaments lie in front of the 
greater. They arise from the sides of the sacrum and the 
coccyx and are inserted into the ischial spines. The open 
space between the lesser sacro-sciatic ligament and the 
ischium is the greater, that between the two ligaments and 
the bone is the lesser sacro-sciatic foramen. 

The greater sacro-sciatic foramen transmits the pyri- 



PHYSIOLOGY OF LABOR. 93 

formis muscle, and the gluteal, the sciatic and the pudic 
vessels and nerves. 

The lesser sacrosciatic foramen transmits the tendon of 
the obturator internus muscle and the internal pudic vessels 
and nerves. 

The cavity of the pelvis is bounded posteriorly mainly by 
the sacrum and the coccyx ; anteriorly by the pubic bones 
and the ischio- pubic rami ; laterally by the surfaces of the 
iliac and the ischial bones. 

The posterior wall is smooth, and is concave from above 
downward, a fact which favors the descent of the posterior 
pole of the foetal head or other presenting part. The depth 
of the posterior wall is 12.5 cm. (5 inches) ; if measured on 
the curve of the sacrum and coccyx, 14 cm. (5 J inches). 
The anterior wall is smooth and concave from side to side. 
This favors the lateral rotation of the head in its screw-like 
descent through the pelvis At the symphysis pubis the 
depth is 4.4 cm. (If inch). The lateral wall is 9 cm. (3J 
inches) deep. 

The obturator foramen, situated in the anterior wall of 
the pelvis, is bounded by the bodies and the rami of the 
ischium and pubis. The bony opening is closed by the 
obturator membrane, except at the obturator canal. The 
canal transmits the obturator nerve and vessels. 

Planes of the Pelvis. 

1. The plane of the brim cuts the ilio-pectineal line and 
the upper margin of the sacrum. In the erect posture of 
the woman the average inclination of the brim to the hori- 
zon is about 60°. 

2. The middle plane cuts the middle of the posterior sur- 
face of the pubic symphysis and the upper border of the 
third sacral vertebra. 

5* 



94 ESSENTIALS OF OBSTETRICS. 

3. The plane of the outlet cuts the tip of the coccyx, the 
ischial tuberosities and the lower end of the symphysis 
pubis. The inclination of the plane of the outlet to the 
horizon is 11°, the summit of the subpubic arch being 
below the level of the tip of the coccyx. 

Practically the plane at which the head escapes from the 
grasp of the bony pelvis is a plane cutting the lower end of 
the sacrum at a point just below the lower end of the 
symphysis. 

Pelvic Diameters. Internal Diameters, (a.) At the 
brim : 

1. True conjugate, from the promontory of the sacrum 
to the upper end of the symphysis, more exactly to the point 
at which the symphysis is crossed by the prolongation of 
the linea ilio-pectinea. 

2. Diagonal conjugate, from the summit of the sub- 
pubic arch to the sacral promontory. 

3. Transverse diameter, the greatest transverse diameter 
of the pelvic brim ; it terminates in a point midway between 
the sacro-iliac joint and the ilio- pectineal eminence on either 
side. 

4. Oblique diameters, extending from the sacro-iliac 
joints, respectively, to the opposite ilio-pectineal eminence; 
R. 0. from the right, L. 0. from the left sacro-iliac joint. 

(6.) At the middle plane : 

1. Antero-posterior diameter, from the upper margin of 
the third sacral vertebra to the middle of the posterior 
surface of the pubis. 

2. Transverse diameters, terminating in points corre- 
sponding to the lower margins of the acetabula. 

3. Oblique diameters, each from the centre of one greater 
sacro- sciatic foramen to the centre of the obturator mem- 
brane opposite. 



PHYSIOLOGY OF LABOR. 95 

(c.) At the outlet : 

1. Anteroposterior diameter, from the lower end of the 
symphysis pubis to the tip of the coccyx, practically to the 
tip of the sacrum. 

Fig. 29. 




c v. True conjugate, d c. Diagonal conjugate, a s. Axis of brim. 
p o. Plane of outlet, h h. Line of horizon. 



2. Transverse diameter, the distance between the tubera 
ischiorum, the bisischial diameter. 

3. Oblique diameters, each from the middle of the lower 
edge of the greater sacro-sciatic ligament on one side to the 
point of union between the ischium and pubis on the oppo- 
site side. 

External Diameters. 1. External conjugate diameter, 
or diameter of Baudelocque, from the depression or fossa 
just below the spinous process of the last lumbar vertebra 
to the most prominent point on the surface overlying the 
upper portion of the pubic symphysis, nearly parallel with 



96 ESSENTIALS OF OBSTETRICS. 

the internal conjugate. To locate the spine of the last 
lumbar vertebra draw an imaginary line connecting the de- 
pressions corresponding to the posterior- superior iliac spines. 
The second spinous process above the level of this line is 
that of the last lumbar vertebra. 

2. Rio-spinal or interspinal diameter, the distance be- 
tween the anterior-superior spines of the ilia measured from 
the outer borders of the sartorius muscles at their origins. 

3. Rio-cristal or intercrislal diameter, in the normal 
pelvis the greatest transverse width of the pelvis at the 
crests. 

Approximate Measurements of the Static or Dried Pelvis. 

Internal Diameters. 



NTERO-POSTERIOR. 


Oblique. 


Transverse. 


Brim, 4 inches. 


4% inches. 


5 inches . 


Cavity, 4% " 


4% " 


4^ " 


Outlet, 5 " i 


4% " 


4 



These values correspond nearly to 10, 11.5 and 12.5 cm. 

At the brim the right oblique diameter is slightly longer 
than the left oblique. The average measurements at the 
brim are more accurately as follows : 

Conjugate. Oblique. Transverse. 

10 cm. (4 in.). 12.5 cm. (5 in.). 13.5 cm. (5% in.). 

The circumference of the brim is about 40 cm. (16 in.) ; 
of the outlet, 33 cm. (13 in.). 

Approximate Measurements of the Dynamic Pelvis. 

Internal Diameters. The internal diameters are all 
reduced 6 mm. (J in.) by the presence of the soft structures 
in the dynamic pelvis. The transverse diameter at the 
brim is still more diminished by the psoas and iliacus mus- 

1 Distance from lower end of symphysis pubis to tip of sacrum 12.5 cm. (5 in.) ; 
to tip of coccyx, 9.5 cm. (3% in.) ; when coccyx is pushed back, 11.5 cm. (4% in.). 



PHYSIOLOGY OF LABOR. 



97 



cles, so much so that the oblique is the longest diameter in 
the dynamic pelvis. 

External Diameters. 

External conjugate 20 cm. (8 inches). 

Interspinal 25.5 " (10 " ). 

Intercristal 28 " (11 " ). 

To estimate the internal conjugate from the external 
deduct 7 to 12.5 cm. (2| to 5 inches) according to the esti- 
mated thickness of the overlying bony and soft parts. 

The average external circumference of the pelvis meas- 
ured over the symphysis and on a line running just below 
the iliac crests and across the middle of the sacrum is nearly 
1 metre (about a yard). 

Difference between the Male and the Female Pelvis. 
Distinguishing Marks of the Female Pelvis. 

As a whole : The greater pelvis is wider ; the lesser 
pelvis is larger in all its diameters and of shallower depth. 

Fig. 30. 




Male pelvis. 



98 ESSENTIALS OF OBSTETRICS. 

The bones are lighter and are more slender. The inclina- 
tion of the pelvis is greater. 

The hrim. The shape is less triangular. The sacro- 
vertebral angle is a little less prominent. The pubic spines 
are more widely separated. 

Fig. 31. 




The female pelvis. 

The cavity is not so funnel-shaped. The sacrum is shorter 
and broader and less strongly curved. 

The outlet. The subpubic angle is greater — 90°, the 
angle in the male being 70°. The depth of the symphysis 
pubis is little more than half that in the male. 

Obstetric Anatomy of the Pelvic Soft Parts. 

The transverse diameter of the hrim is somewhat dimin- 
ished by the iliacus and psoas muscles. They encroach 
upon the lateral margins of the inlet to the extent of a 
quarter of an inch or more on each side. The external 
iliac vessels run along the inner borders of these muscles. 

In the cavity no muscular structures overlie the median 
portion of either the anterior or posterior pelvic wall. On 
either side of the median section are the pyriformis muscle 



PHYSIOLOGY OF LABOR. 99 

posteriorly and the obturator internus anteriorly and later- 
ally, too thin to affect the pelvic diameters. 

The pyriformis arises by a series of digitations from the 
lateral aspects of the sacrum anteriorly and from the upper 
portion of the sacro-sciatic ligament, and its fasciculi con- 
verge to pass out through the greater sacro-sciatic foramen. 

The obturator internus arises from the circumference of 
the obturator foramen and the inner surface of the obturator 
membrane; its fibres converge to a tendon which passes 
through the lesser sacro-sciatic foramen. 

The outlet of the pelvis is closed by the pelvic floor or 
diaphragm, which is made up chiefly of muscles and fasciae. 

The Pelvic Floor. The upper aspect of the pelvic 
floor is concave ; its lower, convex from before backward. 

It is limited above by the peritoneum, except where that 
structure is lifted to be reflected over the pelvic viscera and 
their appendages. Its inferior surface is skin. 

Its median portion is obliquely traversed by three mus- 
cular slits, the urethra, the vagina, the rectum. These 
canals are approximately parallel with the plane of the 
pelvic brim, except that the end of the rectum turns back- 
ward nearly at a right-angle with the vagina. 

The posterior vaginal wall and the soft structures behind 
it make the sacral segment of the pelvic floor ; the anterior 
wall of the vagina and the soft parts in front of it constitute 
the pubic segment of the pelvic floor. (Hart.) 

Measurements. Coccyx to anus, in the nullipara, 4.5 
cm. (If in.) j anus to lower edge of vulvar orifice, in the 
nullipara, 3.1 cm. (1J in.); in the parous woman, 2.5 cm. 
(1 in.) ; in the primigravida at term, 3.8 cm. (If in.). 

Greatest transverse width on the bis-ischial line, 10.7 cm. 
(4J in.). Perpendicular thickness of the pelvic floor at the 
anus, 5 cm. (2 in.). 



100 ESSENTIALS OF OBSTETRICS. 

In the nullipara the average projection of the pelvic floor 
below a line drawn from the tip of the coccyx to the lower 
end of the symphysis is 2.5 cm. (1 in.); in the parous 
woman at term, 9.5 cm. (3f in.). 

The length of the sacral segment during labor at the 
moment of expulsion, coccyx to lower edge of the vulvar 
orifice, is 15 to 17.5 cm. (6 to 7 in.). 

Principal Component Structures. 

Fascial Sheets of the Pelvic Floor. The most im- 
portant supporting structures of the pelvic floor are its fascial 
sheets. Upon these the strength of the pelvic diaphragm 
almost wholly depends. 

Recto-vesical or visceral fascia. It will be remembered that 
the parietal fascia of the lesser pelvis is continuous with the 
iliac fascia*and covers the obturator and the pyriformis mus- 
cles. From this is given off a transverse layer which stretches 
across the pelvis. This is the recto-vesical fascia. Its line of 
attachment to the parietal fascia is the white line, or arcus 
tendineus. The white line extends from the ischial spine 
to the posterior aspect of the body of the pubis, arching 
downward. Its greatest distance below the ilio-pectineal is 
about 5 cm. (2 in.). 

At the lateral walls of the bladder, the vagina and the 
rectum, this fascia divides into four layers (Webster) : 

1. Vesical layer. This layer runs upward on each 
lateral aspect of the bladder to form the lateral true liga- 
ments of the bladder. 

2. Vesico-vaginal layer. This layer runs between the 
bladder and the anterior vaginal wall. 

3. Recto-vaginal layer. This layer extends between the 
lower portion of the vagina and the rectum, blending below 
with the connective tissue of the perineal body. 



PHYSIOLOGY OF LABOR. 101 

4. Rectal layer. This layer envelops the lower end of 
the rectum posteriorly, being closely attached to its poste- 
rior wall. 

The anal fascia covers the inferior surface of the levator 
ani muscles, presently to be described. 

The Triangular Ligament. Across the triangular space 
between the ischio-pubic rami and in front of the bis-ischial 
line are stretched the two fascial sheets which constitute the 
triangular ligament. The deep layer of the triangular liga- 
ment blends with the parietal fascia and is in contact with 
the inferior surface of the levator ani muscle, fusing with its 
fascial sheath. The two layers blend at the bis-ischial line 
with each other and with the superficial fascia. The union 
of these layers at the bis-ischial line forms the perineal 
ledge or ischio -perineal ligament. These three sheets are 
sometimes described as the deep, the middle and the super- 
ficial layers of the perineal fascia. They are perforated by 
the urethra and the vagina. Between the middle and the 
superficial layers of the perineal fascia are the superficial 
transversus perinei, the bulbo-cavernosus and the ischio- 
cavernosus muscles, on either side. 

Muscles of the Pelvic Floor. Levator ani. The anatomy 
of this muscle, according to Browning, who was the first to 
describe it correctly, is as follows : it immediately underlies 
the recto-vesical fascia. It consists of three parts. The 
first takes its origin from the posterior surface of the os 
pubis and from the deep layer of the triangular ligament ; 
the second from the white line ; the third from the ischial 
spine. The bony origin of the pubic bundle is about 
12 mm. (J inch) from the symphysis and 3.5 cm, (1J- inch) 
below the upper border of the bone. The entire pubic 
bundle is about 12 mm. (J inch) wide and 3 mm. (J inch) 
thick at a point just beyond its origin. Its course is nearly 



102 ESSENTIALS OF OBSTETRICS. 

horizontally backward. Its superficial fibres blend with 
those of the external sphincter ani. Of the deeper fibres a 
few turn forward into the perineal body. The greater 
number take a backward course toward the coccyx, to which 
most of them can be traced. Some of the fibres in their 
course toward the coccyx lie in close proximity to the 
median line, but none are continuous with their fellows of 
the opposite side. The pubic bundle as it sweeps by the 
vagina is 5 mm. (J inch) away from it. 

The part of the muscle which arises from the white line 
is thin and membranous and is weakly attached to it. 
The direction of its fibres is at first downward, inward and 
backward toward the rectum and the rectococcygeal raphe. 
They all fall short of the rectum and the raphe, turning 
toward the coccyx, most of them reaching it, some first 
becoming aponeurotic. 

The part of the levator which springs from the ischial 
spine forms a small spindle-shaped bundle. Its course is 
nearly transverse. The most of its fibres are inserted into 
the tip of the coccyx ; a few turn forward upon the recto- 
coccygeal raphe. 

Nowhere do the fibres of the levator cross the median 
line to join those of its fellow on the opposite side. 

The anal fascia on the lower and a very thin fascial 
layer on the upper surface of the levator constitute its 
sheath. These are separable from the contiguous fascial 
sheets previously described. 

Superficial transversus perinei. Origin, the inner aspect 
of the tuberosity and ramus of the ischium : insertion, the 
centre of the perineal body. 

The deep transversus perinei lies between the deep and 
the middle layers of the perineal fascia. It takes origin 



PHYSIOLOGY OF LABOR. 103 

from the descending ramus of the pubis, and is inserted into 
its companion muscle. 

Bulbo-cavernosus. Origin, the external sphincter ani and 
the perineal fascia at one side of it ; insertion, by three slips, 
one into the posterior surface of the bulb, one into the lower 
aspect of the clitoris and one into the vestibular mucous 
membrane. 

Ischio-cavernosus. Origin, the tuberosity of the ischium 
and ischio-pubic ramus ; insertion, the crus clitoridis and 
an aponeurosis covering the posterior part of the body of 
the clitoris. 

The sphincter ani externus is made up of two semilunar 
bands, each about 3 cm. (f inch) wide, one on either side 
of the anus. Origin, the tip of the coccyx and the skin 
adjacent thereto; insertion, the tendinous centre of the 
perineal body. 

The perineal body, so called, is the body of elastic and 
muscular tissue between the lower end of the rectum and 
the vagina. Its height is 3.7 cm. (1J inch), its transverse 
width 3.7 cm. (1J inch), and the length of its base antero- 
posterior^ 3.1 cm. (1J inch) in the nullipara. 

The Parturient Axis. 

The axis of the brim is a line perpendicular to the plane 
of the inlet at its central point ; its prolongation passes 
through the umbilicus and the tip of the coccyx. It is co- 
incident with the axis of the uterus at term. 

The axis of the outlet is the perpendicular to the plane 
of the outlet at its midpoint. Prolonged it cuts the lower 
border of the first piece of the sacrum. 

The axis of the outlet of the soft parts, the line of expul- 
sion, looks almost directly forward, 



104 



ESSENTIALS OF OBSTETRICS. 



The parturient axis is made up of the axes of the several 
planes of the birth-canal. It is an irregular parabola. 



Fig. 32. 




Axes of the pelvis. A Axis of superior plane. B. Axis of mid-plane. C. Axis 
of inferior plane. D. Axis of canal. E. Horizon (Playfair.) 



3. The Passenger. 

Obstetric Anatomy of the Fcetal Head. 

For the obstetrician the foetal head presents two divisions : 
1. The cranial vault. 2. The cranial base and face. The 
former owing to the semi-cartilaginous character of its bones 
and to their mobility is plastic, a fact of importance in 
facilitating the passage of the head through the pelvis ; the 
latter is unyielding, its bony structures being more highly 
ossified and more firmly united. Protection is thus afforded 
during labor to the vulnerable structures at the base of the 



PHYSIOLOGY OF LABOR. 105 

brain. It is with the cranial vault that obstetric problems 
have mainly to do. 

The cranial vault comprises the parietal, the frontal and 
the squamous portions of the occipital and the temporal 
bones. 

The cranial base is composed of the basilar portion of 
the occipital bone, the petrous portion of the temporal bones 
and of the entire sphenoid and ethmoid bones. 

The Sutures. The sutures are the membranous inter- 
spaces between two adjacent cranial bones. Of special ob- 
stetric importance are the following : 

The sagittal or inter-parietal suture ; 
The frontal or inter-frontal suture ; 
The coronal or fronto parietal suture; 
The lambdoidal or occipito-parietal suture. 

The Fontanelles. The fontanelles are the membranous 
spaces between the angles of three or four adjacent bones of 
the cranium. The fontanelles of obstetric interest are two, 
the anterior and the posterior. 

The anterior or large fontanelle or bregma is situated 
at the anterior end of the sagittal suture. In the vaginal 
examination during labor it is identified by the following 
characters : 

1. It is kite-shaped or quadrangular, its most acute angle 
looking forward ; 2. Its average diameter is 2.5 cm. (1 in.) ; 
3. Four sutures run into it. 

The posterior fontanelle lies at the posterior end of the 
sagittal suture. To the examining finger it presents the fol- 
lowing distinguishing marks : 

1. It is triangular ; 2. It is small, usually a mere de- 
pression scarcely perceptible to the finger-tip ; 3. Three 
sutures run into it ; 4. Immediately behind it is the squa- 
mous or triangular portion of the occipital bone which is 



106 ESSENTIALS OF OBSTETRICS. 

hinged to the basilar portion by a movable joint of fibrous 
tissue. 

Protuberances. The foetal head presents five protuber- 
ances which are of interest as obstetric landmarks, viz., one 
occipital, two parietal and two frontal. 

The occipital protuberance is situated on the occipital 
bone an inch or more behind the posterior fontanelle. 

The parietal protuberance or boss on either side of the 
cranium is the eminence at the centre of the parietal bone. 

The frontal protuberance is the prominence at the central 
portion of each frontal bone. 

The Vertex. The vertex is that part of the cranial vault 
lying between the fontanelles and extending laterally to the 
parietal eminences. 

The Occiput. The occiput is the portion of the cranium 
behind the posterior fontanelles. 

The Sinciput. The sinciput is that portion of the cranial 
vault lying in front of the bregma. 

Measurements of the Foetal Head. 

The biparietal diameter is the greatest transverse width 
of the head measured through the parietal eminences ; its 
value is 9.5 cm. (3f inches). 

The fr onto mental diameter extends from the summit of 
the forehead to the centre of the lower margin of the chin. 
Its value is 9 cm. (3J inches). 

The trachelo-bregmatic diameter is measured from the 
neck just above the larynx to the centre of the bregma ; its 
value is 9.5 cm. (3f inches). 

The occipitofrontal diameter is the distance from the tip 
of the occipital protuberance to the root of the nose ; its 
value is 11.5 cm. (4J inches). 

The occipito-mental diameter is measured from the sum- 



PHYSIOLOGY OF LABOR. 107 

mit of the occipital protuberance to the centre of the lower 
margin of the chin ; its value is 14 cm. (5 J inches). 

Fig. 33. 




Foetal head viewed from behind. P P. Biparietal diameter. (After Farabeuf.) 

The suboccipito-bregmatic diameter is the distance from 
the junction of the nucha and the occiput to the centre of 
the bregma; its value is 9.5 cm. (3f inches). 

The bitemporal diameter is the transverse diameter of 
the head between the lower extremities of the coronal 
suture ; its value is 8 cm. (3J inches). 

The bimastoid diameter is the greatest distance between 
the mastoid apophyses ; its value is 7 cm. (2f inches). 

Circumference. The suboccipito-bregmatic circumference 
is measured over the junction of the nucha and occiput and 
over the centre of the bregma ; its value is about 33 cm. 
(13 inches), in male — 1.2 cm. (J inch) greater than in female 
heads. 



108 



ESSENTIALS OF OBSTETRICS. 

Fig. 34. 




Foetal head viewed from the side. F. Occipitofrontal diameter. B. Sub- 
occipito-bregmatic diameter. T B. Trachelo-bregmatic diameter. (After Fara- 
beuf.) 

It will be seen that the principal diameters of the foetal 
head, namely, the biparietal (also the fronto-mental), the 
occipito-frontal, and the occipito-mental, are approximately 
3^, 4J, 5J inches respectively. 

Trunk Diameters. 

The bisacromial diameter is 12 cm. (4f inches). The bi- 
trochanteric is 8.8 cm. (3J inches). The trunk diameters 
are much more compressible than are the cephalic. 

Presentation, Position and Posture op the Foetus. 

Presentation. Definition. By presentation is meant 
the relation of the long axis of the fcetal ovoid to the uterine 
axis. 



PHYSIOLOGY OF LABOR. 109 

Varieties : 

1. Longitudinal. 

A. Cephalic, 

a. Vertex ; 

b. Face; 

c. Brow. 
A. Pelvic, 

a. Breech ; 

b. Feet. 

2. Transverse. 

a. Shoulder; 

b. Arm; 

c. Hand. 

The presenting part is that part of the foetal ovoid which 
offers to the examining finger within the girdle of resistance. 

Relative frequency of presentations. In at least 96 per 
cent, of all term labors the foetus presents by the cephalic 
extremity. Breech or pelvic presentation occurs in 3 per 
cent, of term births, lateral in about 1 per cent. The face 
or brow is the presenting part in a little less than -f^ per 
cent, of cephalic births. The preponderance of cephalic 
presentation is mainly due to adaptation ; the foetal mass 
tends to accommodate its position to the shape of the uterus. 

Position. Position is the relation of the presenting part 
to the quadrants of the pelvic brim. These quadrants are 
the left anterior, the right anterior, the right posterior and 
the left posterior quadrant of the brim. The positions are 
named according to the particular quadrant which the lead- 
ing anatomical landmark on the presenting part confronts. 
For each presenting part there are, therefore, four possible 
positions. 

Vertex positions are named according to the quadrant 
which the occiput confronts. When the occiput looks toward 



110 ESSENTIALS OF OBSTETRICS. 

the left anterior quadrant the position is left occipitoante- 
rior ; when toward the right anterior quadrant the position 
is right occipitoanterior, and so on. Face positions are 
named in like manner, according to the direction of the 
chin ; breech positions with reference to the direction of the 
sacrum, and shoulder positions to that of the scapula. 
Thus we have the following positions : 
Vertex Positions. 

Left occipitoanterior — L. 0. A. 
Right occipito-anterior — R. 0. A. 
Right occipito-posterior — R. O. P. 
Left occipito-posterior — L. 0. P. 
Relative frequency : 70, 10, 17, and 3 per cent, respec- 
tively. 

Face Positions. 

Left mento-anterior — L. M. A. 
Right mento-anterior — R. M. A. 
Right mento-posterior — R. M. P. 
Left mento-posterior — L. M. P. 
Breech Positions. 

Left sacro-anterior — L. S. A. 
Right sacro-anterior — R. S. A. 
Right sacro-posterior — R. S. P. 
Left sacro-posterior — L. S. P. 
Transverse or Shoulder Positions. 
Left scapuloanterior — L. Sc. A. 
Left scapulo-posterior — L. Sc. P. 
Right scapulo-posterior — R. Sc. P. 
Right scapulo-anterior — R. Sc. A. 
Note that in shoulder as in other presentations the terms 
right and left refer to the mother. 

Posture. By posture is meant the relation of the foetal 
members to one another. The usual foetal posture during 



PHYSIOLOGY OF LABOR. HI 

pregnancy and parturition is one of flexion. As an ele- 
ment in the labor posture is most important as relates to 
the head. 

n. CLINICAL AND MECHANICAL PHENOMENA OF 
NORMAL LABOR. 

Normal labor, as we shall define it, includes only labor 
in which all the mechanical factors are normal and which 
are otherwise uncomplicated — labors, in other words, having 
no element of dystocia. Only vertex births in one of the 
anterior positions will be classed as normal. 

Stages of Laboe. 

The first stage, or stage of dilatation, ends with the com- 
plete dilatation or canalization of the utero-cervical zone. 

The second stage, or stage of expulsion, ends at the birth 
of the child. 

The third, or placental stage, includes the expulsion of 
the placenta, the complete evacuation and persistent retrac- 
tion of the uterus. 

Causes of the Onset of Labor. 

The causes which determine the advent of labor are not 
definitely known. Probable causes are : the loosening at- 
tachment of the ovum in the later weeks of gestation ; 
distention of the uterus and the consequent reaction of the 
uterine muscles; development of the contractile power of 
the uterus ; the growing vigor of the foetal movements ; 
excess of carbonic dioxide in the blood, acting upon the 
motor centres ; increasing irritability of the uterus ; the in- 
fluence of the menstrual molimen. The separation of the 
decidua begins at the lower uterine segment with the first 



112 ESSENTIALS OF OBSTETRICS. 

labor pains. The ovum thus becomes in part a foreign 
body. This furnishes sufficient stimulus for continued 
expulsive efforts. 

Phenomena of Beginning Labor. 

Signs of the onset of labor are : 

Lightening ; 

Irritability of the bladder and rectum ; 

Increased flow of vaginal secretion ; 

The show, a discharge of bloody mucus from the 
vagina; 

Expulsion of the cervical mucous plug; 

Rhythmic uterine pains. 
By lightening is meant the sinking of the uterus, which 
takes place usually within from ten to fourteen days before 
labor actively begins. The uterus sinks more deeply in the 
pelvis. The waist-line becomes smaller. As the uterus 
settles lower down in the pelvis the pressure on the bladder 
and rectum is increased and these viscera are evacuated 
oftener than is the usual habit. Lightening, however, is 
not observed in all cases. 

At the onset of active labor urination and defecation 
become still more frequent and there is a profuse secretion 
of vaginal and cervical mucus. The vaginal discharge may 
be stained with blood — the show. Sometimes the mucous 
plug which blocks the cervix during pregnancy is expelled 
as a tenacious, jelly-like mass. 

The most reliable evidences of beginning labor are the 
occurrence of rhythmic uterine pains and contraction of 
the uterus with each pain as felt by the examining hand 
held upon the abdomen. The first pains are often little 
more than a sense of pressure, and are felt in the lumbo- 
sacral region. As labor advances they become more pro- 



PHYSIOL OGY OF LABOR. 113 

nounced, extend in front to the lower abdominal region 
and radiate down the thighs. 

Labor pains. Labor pains are the painful uterine con- 
tractions of labor. The painful character of the contrac- 
tions is due to pressure on the nerve-filaments of the uterus 
and on the nerve-trunks in the pelvic cavity. 

The duration of a pain is thirty to sixty seconds. The 
usual intervals between the contractions at the beginning of 
labor are twenty to thirty minutes. They gradually shorten 
as labor goes on and may be reduced to a fraction of a 
minute at the acme of expulsion. 

The intensity progressively increases, reaching its maxi- 
mum at the expulsion of the head from the vaginal outlet. 

1. First Stage : Stage of Dilatation. 

Dilatation. Three agencies are concerned in dilata- 
tion of the cervix : 

1. Traction of the longitudinal muscular fibres of the 
upper uterine segment ; 

2. Hydrostatic pressure of the bag of waters ; 

3. Softening of the cervical structures by serous infiltra- 
tion. 

The traction of the upper segment of the uterus draws 
the lower segment upward over the presenting portion of 
the ovum. The dilatation begins at the os internum. With 
the first active labor pains the ovum is partially detached from 
the lower uterine segment. The internal os expands and 
the bag of waters protrudes into the cervical zone with each 
pain, receding in the intervals. At first the cervix, becom- 
ing somewhat funnel-shaped during the pains, nearly re- 
gains its cylindrical form in the intervals. As the labor 
advances the os internum is permanently effaced and the 
ovum rests against the os externum. From this time the 



114 ESSENTIALS OF OBSTETRICS. 

progress of canalization is indicated by the size of the 
external os. 

The bag of waters is the portion of the membranes which 
in the course of the labor protrudes downward into the 
cervix. It plays an important part in the mechanism of 
dilatation. Its contained liquor amnii, the fore-waters, 
is partly cut off from that above the head, the hind-waters, 
by the ball-valve action of the head as the latter is driven 
into the cervix during a pain. The general uterine press- 
ure, however, is transmitted in some measure to the fore- 
waters. In accordance with the law of hydrostatics the bag 
of waters is not only urged downward, but it exerts a cer- 
tain amount of expansive force upon the walls of the pas- 
sive cervical zone. In vertex presentation the bag of 
waters has a watch-glass shape. 

When the membranes rupture prematurely the dilatation 
of the cervix usually goes on more slowly and is more 
painful. The foetal head is not so good a dilator as the 
fluid wedge, the bag of membranes. It lacks the active 
dilating power and the equable pressure of the bag of 
waters. The mechanical disadvantage is still greater in 
malpresentations and malpositions, by reason of the greater 
inequality of pressure on different parts of the resisting 
girdle. 

The membranes rupture usually by the time they reach 
the pelvic floor, often sooner, or only on interference. 

Softening of the cervix, established before labor, is much 
increased in course of the first stage. During a pain the 
walls of the uterus are everywhere compressed by contrac- 
tion upon its contents, except at the cervix. The blood- 
vessels of the cervix, unsupported by pressure, become 
engorged, and a serous transudation takes place into its 
tissues, loosening its structure. 



PHYSIOLOGY OF LAB OB. 



115 



detraction ring. In course of the first stage of labor 
the upper uterine segment becomes thickened, retraction of 
the muscular structures into that segment taking place with 
each pain ; the lower segment becomes correspondingly 
thinned. The line of demarcation between the thickened 
upper and the thinned lower segment is the contraction 



Fig. 35. 




The uterus after complete canalization of the utero-cervical zone. CR. Con- 
traction ring or retraction ring. oi. Os internum, oe. Os externum. 

ring, or, as it may more properly be termed, the retraction 
ring. The retraction ring can generally be felt above the 
brim by the close of the first stage, and it rises higher in 
proportion to the number and strength of the pains. 



116 ESSENTIALS OF OBSTETRICS. 

Retraction of the pubic segment. The posterior wall of 
the bladder and the whole pubic segment of the pelvic floor 
begin to be drawn upward during the latter part of the 
stage of dilatation. The elevation is marked during the 
second stage. The bladder is thus lifted partly out of the 
lesser pelvis away from injurious pressure during the birth. 
Only a very small portion of the organ rises above the level 
of the pubic bones. The length of the urethra remains 
unchanged. 

The duration is from two or three hours to several days- 
The average length of this stage is in primiparse, eleven 
hours ; in nmltiparse, seven hours. 

2. Second Stage : Stage of Expulsion. 

The Mechanism of Labok. The most important 
mechanical phenomena of the second stage of labor are 
those pertaining to the series of passive movements which 
the foetus undergoes in course of its expulsion through the 
birth-canal. This succession of movements is usually termed 
the mechanism of labor. 

The engaging diameters of the head being larger than 
those of any part of the foetal mass, the essential mechanical 
phenomena of the stage of expulsion are those pertaining to 
the birth of the head. To rightly comprehend them it 
must be borne in mind that the foetal head is an irregular 
ovoid body, which in typical labors tightly fits the passages ; 
and that the shape and direction of the parturient tract 
change at every point throughout its length. The essential 
cause of the head movements is adaptation or accommoda- 
tion of the head to the varying shape and course of the 
birth-canal. These movements are descent, flexion, rota- 
tion, extension ; restitution and external rotation are addi- 
tional movements impressed upon the head after its escape 



PHYSIOL OGY OF LAB OB. 117 

from the passages, in consequence of the spiral motion of 
the trunk in course of its descent. 

Descent. In the stage of expulsion the uterine contrac- 
tions are reinforced by the action of the abdominal muscles. 
Hence the bearing-down character of the pains at this period. 
Before escape of the waters the expellent force is trans- 
mitted to the head through the entire uterine contents. After 
rupture of the membranes the propelling force acts directly 
upon the foetus. The foetal mass under the general uterine 
pressure moves in the direction of least resistance, through 
the birth-canal. 

The head advances with the pains and recedes in the 
intervals, and in normal conditions this advance and reces- 
sion continue till the head is well in the grasp of the vulvar 
ring. 

Flexion. A certain degree of flexion is present primarily. 
It belongs to the normal posture of the foetus in utero. The 
primary flexion is increased as the descent begins, and for 
this reason : the head is so hinged upon the trunk that the 
occipitofrontal diameter corresponds to a lever of unequal 
arms, the frontal arm being the longer. On engagement 
in the utero- cervical zone the resistance, though equal at 
the two ends of the lever, acts with greater effect on the 
longer or frontal arm, and the chin dips toward the sternum. 
Flexion is still more increased when the head encounters 
the greater resistance of the bony canal. 

The advantage of flexion is apparent. It substitutes the 
suboccipitobregmatic diameter, 9.5 cm. (3f inches), for 
the occipito-frontal, 11.5 cm. (4 J inches), a gain quite 
enough in most cases to make all the difference between a 
possible and an impossible delivery. The head undergoes 
still further accommodation to the passages by the mould- 
ing yet to be described. 

<5* 



118 ESSENTIALS OF OBSTETRICS. 

Rotation. The longest diameter of the pelvis at the 
brim which is available for the passage of the head is the 
oblique ; at the outlet the longest is the antero-posterior. 
The head, therefore, as it descends must rotate about the 
axis of the birth-canal to keep its longest engaging diameter 
constantly in the longest diameter of the pelvis during its 
passage through it. 

Rotation of the head is due chiefly to the slope of the 
lateral halves of the pelvic floor downward, forward and 
inward. In normal labor the occipital pole first lands upon 
one lateral half of the floor, and as it descends it is thrust 
forward and inward beneath the pubic arch. A firm pelvic 
floor, together with efficient labor pains, is, therefore, essen- 
tial to forward rotation of the occiput. Flexion, moulding 
of the head and the development of the caput succedaneum, 
yet to be described, promote rotation by increasing the dip 
of the occipital pole. After the occiput has sunk below the 
level of the pubic arch its forward rotation is due partly to 
the fact that this is the direction of least resistance. Com- 
plete rotation is seldom observed. The head is usually 
expelled in a position slightly oblique to the median antero- 
posterior plane of the parturient outlet. 

Extension. After the occiput has escaped beneath the 
pubic arch the nape of the neck rests against the subpubic 
ligament, and the head, rotating upon the nucha as a pivotal 
point, is born by a movement of extension, the vertex, the 
forehead and the face successively sweeping over the peri- 
neum. The chin, however, does not, as formerly assumed, 
leave the sternum till the moment of expulsion. A brief 
pause usually follows the birth of the head. 

Restitution. Since the shoulders descend in the oblique 
diameter opposite that in which the head engages, rotation 
of the head during its descent through the pelvis brings 



PHYSIOL OOY OF LAB OB. 119 

about a certain degree of torsion of the neck. After the 
head is born the neck untwists and the head, if left to 
itself, takes a position corresponding to that in which it 
entered the pelvis. This movement is termed restitution. 
It may be utilized as a means of confirming the diagnosis 
of position. 

External rotation is a still further rotation of the head 
which is observed during the expulsion of the body ; it 
occurs in consequence of the spiral movement of the trunk 
as it traverses the birth-canal. 

Birth of the trunk. The shoulders and the breech rotate 
to some extent as they descend through the pelvis, but less 
perfectly than the head. The rotation takes place in a 
direction opposite to that of the head, since the shoulders 
and breech come down in the opposite oblique diameter of 
the pelvis. The anterior shoulder is expelled first, or it 
lodges behind the pubic bones and the posterior shoulder 
first appears at the ostium vaginae and escapes over the edge 
of the vulvar ring. A gush of bloody water generally ac- 
companies the birth of the trunk. 

Other Phenomena : Caput succedaneum. The caput 
succedaneum is an cedematous swelling developed upon the 
presenting part of the foetus after rupture of the membranes. 
In cephalic presentation it forms on the part of the head 
within the girdle of resistance. The vessels here, unsup- 
ported by pressure during the uterine contractions, become 
engorged and serous infiltration of the tissues ensues. The 
size of the tumor increases with the number and strength of 
the pains. Its location differs with the position in which 
the head has entered the pelvis. In L. 0. A. positions it 
forms on the right, in R. 0. A. upon the left, posterior 
parietal region. In R. 0. P. positions it appears upon the 
left anterior, and in L. 0. P. upon the right anterior, parietal 



120 ESSENTIALS OF OBSTETRICS. 

region. The location, however, may be modified when the 
head has rested long in the lower portion of the birth-canal 
after having undergone partial rotation. 

Moulding of the head. Owing to the plasticity of the 
cranial vault the adaptation of head to pelvis is in part 
accomplished by moulding. Under pressure of the pelvic 
walls the engaging diameters of the cranial vault are re- 
duced and the head is elongated in the direction of the 
passages. 

Perineal stage. As the occiput approaches the outlet 
of the soft parts the sacral segment of the pelvic floor is 
stretched and pushed downward and forward in front of the 
advancing head. Its length from coccyx to posterior com- 
missure is increased at the moment of expulsion to 13 cm. 
(5 or 6 inches). The sphincter ani is relaxed, the anal 
orifice gapes widely and feces are usually expelled from the 
rectum as the head passes over the pelvic floor. As the 
equator of the head escapes from the vulvo-vaginal orifice 
the posterior segment of the floor promptly retracts over the 



Pulse and temperature. The maternal pulse-rate is some- 
what accelerated during the pains. The maternal temper- 
ature, particularly in hard labor, is generally a degree or 
more above the normal at the termination of the birth. 

The foetal pulse-rate is retarded at the height of the 
pains, owing to increased arterial tension in the foetus. 

The length of the second stage in primiparae is from one 
to seven hours — average about two hours ; in multipara, 
fifteen minutes to two hours — average about one hour. 

3. Third Stage : Placental Stage. 

Events. 1. Separation of the placenta; 2. Expulsion 
of the placenta and blood-clots ; 3. Retraction of the uterus. 



PHYSIOLOGY OF LABOR. 121 

Separation of the placenta takes place in the meshy layer 
of the decidua ; it is brought about partly by contraction of 
the placental site and partly by the extruding force of the 
uterine contractions. 

Expulsion of the placenta is effected by the extruding 
force of the uterine contractions. The after-birth may 
present by its amniotic surface or may be expelled edge 
first. Its expulsion from the vagina is explained by the 
tonicity of the muscular structures in the posterior seg- 
ment of the pelvic floor. The placenta drags the mem- 
branes after it, gradually peeling them from the uterine 
walls. 

Retraction of the uterus consists in a thickening and short- 
ening of its walls, due in part to rearrangement of the 
muscular fibres, in part to thickening and shortening of the 
fibres themselves. Normally retraction of the upper seg- 
ment is promptly established at the close of labor. It 
securely ligates the uterine vessels which have been torn 
across by separation of the placenta. The lower segment 
remains passive for several hours after the close of labor. 

The duration of the third stage varies from a few minutes 
to two hours. Its average length is from twenty to thirty 
minutes. 

The average length of normal labor is in primipar?e twelve 
hours ; in multipara, eight hours. Variations from two to 
twenty-four hours are not uncommon within normal limits. 

III. MANAGEMENT OF LABOR. 

Preparatory. The duties of the obstetrician to his 
patient especially in the later months of pregnancy are 
scarcely less important than those pertaining to the manage- 
ment of labor and the post-partum period. The enforce- 



122 ESSENTIALS OF OBSTETRICS. 

merit of hygienic rules, attention to the general health, 
urinary examinations once weekly or oftener during the 
last two or three months and instructions with reference to 
the care of the nipples are essential to the proper conduct 
of the obstetric case. At this period, too, the physician 
acquaints himself in so far as possible with the conditions 
with which he will have to deal in the subsequent care of 
the patient. A month before the expected date of labor a 
systematic examination should be made according to the 
following plan : 

Ante-partum Examination. 

Scheme. 
History. 

General health ; 

Character of previous pregnancies, labors, puerperiums, 

miscarriages ; 
Date of last menses ; 

Important data concerning the present pregnancy ; 
Character of the vaginal discharge. 

Abdominal Examination. 

Pendulous abdomen ; 
Hydramnios ; 
Twins ; 

Location of placenta ; 
Complicating tumors ; 

Presentation, position, and posture of foetus ; 
Length of the foetal ovoid ; 
Size and hardness of the foetal head ; 
Foetal pulse-rate ; 

External measurements of the pelvis in primiparse and 
in multipara with a history of difficult labors. 



PHYSIOLOGY OF LABOR. 123 

Vaginal Examination. 

Former injuries — pudendal, vaginal, cervical ; 

Placenta prsevia; 

Obstructing tumors ; 

Measurements of the diagonal conjugate and other 
diameters of the pelvis in primiparse and in multi- 
para whose history excites suspicion of pelvic con- 
traction. 

Method of Abdominal Examination for Presentation and 
Position. 

1. Preparation. The patient is placed in the horizontal 
posture (supine, with the lower limbs extended) with the 
abdomen fully exposed or covered only with a sheet. When 
the sheet is used the examination may be conducted through 
this covering, or, better, with the hands underneath it. Be- 
fore examining the hands of the operator are bathed in warm 
water to render the sense of touch more acute, and because 
contact of cold hands would excite reflex contractions of the 
abdominal and uterine muscles which interfere with the 
examination. 

2. Locating the dorsal plane and small parts. 

This is done by any one or all the following methods : 

a. The entire surface of the abdomen is palpated 
systematically, using light touches with the palmar 
surfaces of the finger-tips. 

b. Downward pressure is applied with one hand 
on the foetal pole in the direction of the uterine 
axis ; this steadies the dorsum and brings it nearer 
to the abdominal wall where it can more satis- 
factorily be palpated with the other hand. The 
child's back is identified by the length and breadth 
of the resisting plane. Distinguish from the 



124 



ESSENTIALS OF OBSTETRICS. 



lateral plane by the greater width of the dorsal, 
by its convexity and by the absence of a sulcus 
between it and the head. 



Fig. 




Displacing foetus to one side of abdomen for locating dorsal plane. 



c. Place the palmar surface of one hand flat on the 
median section of the abdomen at the umbilicus, 
and press backward toward the spinal column. 
The child will be displaced to the side toward 



PHYSIOLOGY OF LABOR. 



125 



which its back lies and the liquor amnii to the 
other. Palpating with the other hand, the solid 
is readily distinguished from the fluid tumor. (Fig. 
36.) 
Small parts are felt as nodules which glide freely about 
under the touch ; sometimes their outlines may be fully 



Fig. 37. 




HI ■ mmS 




■ If i \ f ■ F 




ml .^FBbmw JA f / / 


PS 




i 



Examining lower foetal pole. 



traced. Circular rubbing movements with the finger-tips 
help to identify them. They are felt on the side opposite 



126 



ESSENTIALS OF OBSTETRICS. 



the foetal dorsum. In full anterior positions of the child's 
back the small parts may not be accessible to palpation. 
Small parts in the median section of the abdomen indicate 
a dorso-posterior position of the foetus. 

3. Examining the lower foetal pole. With both hands 
over the lower uterine segment just above Poupart's liga- 

Fig. 38. 




Grasping foetal head with hand over abdomen for locating cephalic prominence. 

ments, finger-tips toward the mother's feet, and palmar 
surfaces nearly facing each other, the lower foetal pole is 



PHYSIOLOGY OF LABOR. 



127 



caught between the hands. (Fig. 37.) In difficult cases 
the following manipulation helps to find the head : bringing 
the hands gradually nearer and nearer together, while placed 
as above described, move them as if to toss the head sharply 
from one hand to the other. 

The head feels hard and globular ; there is a lateral sulcus 
between it and the trunk ; in primipara (not in multipara) 
it is in the pelvic excavation before labor. 

The breech alone is smaller, with all its component ele- 
ments it is larger, than the head ; it lacks the hard and 
globular feel of the head, presents no sulcus and it is 
never in the excavation before labor. If small parts can be 
felt just beyond either foetal pole that pole is the breech. 

The head in either iliac fossa indicates a cross-birth. 



Fig. 




Locating cephalic^prominence with one hand. 



128 ESSENTIALS OF OBSTETRICS. 

Cephalic prominence. When the head is in the brim the 
cephalic prominence is greatest on the side of the sinciput. 
The location of the cephalic prominence affords some aid in 
deciding whether the child's back lies to the right or the left. 
It is located by grasping the head with one hand held trans- 
versely across the suprapubic region (Figs. 38, 39), or by 
palpation with both hands (Fig. 40). The hand sinks most 
deeply in the excavation on the side opposite the prominence. 

Fig. 40. 




Locating cephalic prominence by palpation with both hands. 

4. Examining the upper foetal pole. With both hands over 
the upper uterine segment, finger-tips toward the mother's 
face (Fig. 41) and palmar surfaces nearly facing each other, 
the foetal poles are differentiated by the signs already given 
and by ballottement of the head. The breech lacks the flex- 



PHYSIOLOGY OF LABOR. 



129 



ible attachment to the trunk which characterizes the head, 
and it has less mobility by reason of this and of its greater 
bulk when taken with all its component parts. Ballotte- 
ment of the head when in the lower uterine segment is 
possible -only with -excess of liquor amnii. 

Fig. 41. 




Examining upper fcetal pole. 



5. Locating the anterior shoulder. The hands are placed 
over the sides of the head and, with firm pressure, moved 
toward the breech ; the first obstacle they encounter is the 



130 



ESSENTIALS OF OBSTETRICS. 



anterior shoulder. It can usually be identified by its ana- 
tomical characters. (Fig. 42.) 



Fig. 42. 




Locating anterior shoulder. 



Location of the anterior shoulder within one or two 
inches of the median line indicates an anterior position of 
the child's back ; anterior shoulder several inches away 



PHYSIOLOGY OF LABOR. 131 

from the median line indicates a posterior position of the 
child's back. 

6. Locating the foetal heart. The place at which the 
foetal heart-tones are heard loudest is called the focus of 
auscultation. It is usually an area of about 7 5 cm. (3 
inches) in diameter. As a rule it lies nearly over the lower 
angle of the left scapula of the foetus, or at least the upper 
part of the foetal dorsum. Heart-sounds in the upper 
uterine segment indicate a breech, in the lower a cephalic 
presentation. The heart, however, is situated nearly mid- 
way between the ends of the foetal ellipse. In multipara, 
therefore, in whom neither pole sinks into the lesser pelvis 
before labor begins, the location of the foetal heart-tones is 
of little value for the diagnosis of presentation. 

Occasionally the focus of auscultation does not imme- 
diately overlie the heart. It may be found at some remote 
point owing to firmer contact of the foetus with the uterine 
wall at that point. 

The location of the foetal heart is especially useful in 
distinguishing between right and left and between anterior 
and posterior positions of the child's back. Heart-tones to 
the left indicate a left, to the right a right, position ; heart- 
tones near the median line indicate an anterior, far from it 
a posterior, position. 

External Pelvimetry- Measurement of the external diam- 
eters requires the use of a suitable instrument. A good 
portable pelvimeter for external measurements is Schultze's 
or Collyer's. (Fig. 43.) Marked asymmetry of the pelvis 
is sometimes apparent on external palpation. 

Interspinal and intercristal diameters both small indi- 
cates general pelvic contraction. Interspinal equal to or 
greater than the intercristal indicates antero-posterior flat- 
tening. For the external conjugate 7 inches may be taken 



132 ESSENTIALS OF OBSTETRICS. 

as the average lower limit m normal pelves. Yet variations 
of J to 1 inch above or below this limit are observed. 

Fig. 43. 




Collyer's pelvimeter. 

Method of Vaginal Examination and Internal Pelvimetry. 

The bladder and the rectum must be empty. Antiseptic 
precautions are to be observed as in examinations during 
labor. Measure the depth of the symphysis pubis, width 
of the subpubic angle, the bisisohial, the sacro-pubic and 
the diagonal conjugate diameters and note the size and 
shape of the sacrum. 

The transverse diameter at the outlet ma} T be measured 
externally by taking the distance between the inner aspects 
of the ischial tuberosities measured on a line drawn through 



PHYSIOLOGY OF LABOR. 



133 



the anterior margin of the anus. It may be measured in- 
ternally with the aid of a suitable instrument, approxi- 
mately by the hand. 

The antero-posterior diameter at the inferior strait is ob- 
tained in a manner similar to that described below for the 
diagonal conjugate. It may more readily be measured exter- 
nally with a pelvimeter. 

The diagonal conjugate is measured as follows : Passing 
the index and second finger into the vagina, the tip of the 



Fig. 44. 




Measuring the diagonal conjugate. 

second is placed against the summit of the promontory, the 
radial edge of the hand resting against the subpubic liga- 
ment. The latter point of contact is marked with the index 
finger of the other hand. Withdrawing the hand the dis- 
tance between the two points of contact is measured. This 
distance is the diagonal conjugate. (Fig. 44.) 

The true conjugate is found by deducting 1.3 to 2 cm. 

7 



134 ESSENTIALS OF OBSTETRICS. 

(J to f inch), according to the depth and inclination of the 
symphysis pubis, from the diagonal — one-half inch when the 
symphysis measures less, three-fourths inch when the sym- 
physis measures more, than 4.5 cm. (If inch). 

The other diameters are estimated by palpating the walls 
of the cavity. 

General Preparations for Labor. 

The lying-in room. The lying-in room should be a 
large, well-ventilated room, with sanitary plumbing, or none 
at all, preferably with a southern exposure. The room, the 
bedding and the clothing of the patient must be absolutely 
clean. 

Preparation of the bed. Directions for the nurse. 
The mattress should be covered with a muslin sheet, and 
that with a rubber sheet large enough to reach across the 
bed. A clean muslin sheet is spread over the rubber and 
pinned fast to the mattress. Over that is spread a second 
rubber covered with a muslin sheet. Two or three fresh 
laundered sheets, twice folded, are placed in position to re- 
ceive and absorb the discharges. The rubber and the 
muslin sheets must be surgically clean. 

Labor pad. In place of the folded sheets an aseptic 
pad of prepared cotton, cotton-waste, paper-wool or other 
absorbent material, covered with cheese-cloth, may be used 
to receive the discharges. It ought to be two and a half to 
three feet square. A large Kelly rubber pad may be sub- 
stituted for the absorbent pad. 

Obstetric Armamentarium. For general practice the 
obstetric bag should be equipped with obstetric forceps, a 
pelvimeter, a soft- rubber catheter, a hypodermic syringe, a 
fountain syringe, a uterine douche-tube of glass, needles, 



PHYSIOLOGY OF LABOR. 135 

needle-forceps, aseptic sutures, hand brushes, a Sims' specu- 
lum, a sponge-holding forceps, a volsella, a curette and a 
yard of aseptic gauze. 

It should also contain four ounces of Squibb's chloroform, 
an ounce of Squibb's ergot, a few drachms of chloral, mor- 
phia tablets gr. J, fluid extract of veratrum viride and 
antiseptic tablets of the biniodide or bichloride of mercury, 
or either of the following powders. 

R . — Hydrargyri biniodidi, 

Potassii iodidi. — M. 
Chart, no. viii. 
S. One to a quart of warm water, as an antiseptic solution. 

R. — Hydrargyri bichloridi, 

Acidi tartarici. — M. 
Chart, no. viii. 
S. One to a quart of warm water, as an antiseptic solution. 

The nurse should have ready a half dozen clean 
sheets, a dozen recently laundered towels, a dozen pieces 
of cheese-cloth 45 cm. (18 inches) square, for wash-cloths ; 
two or three pieces of unbleached muslin for binders, 
a little over a meter long by 50 cm. wide (1J by J 
yard) ; two surgically clean rubber sheets wide enough to 
reach across the bed (table oil-cloth may serve when 
economy requires) ; scissors, two dozen shield-pins of 
medium size ; a bed-pan of earthenware or of agate iron- 
ware, two or three clean hand-basins of like material, a 
slop-jar, one or more new hand-brushes, plenty of hot and of 
cold water, a yard of strong linen bobbin, one-sixteenth of 
an inch in width, for tying the navel cord ; a woollen 
blanket to wrap the child in, an infant's bath-tub and a 
bath-thermometer, Castile soap, an ounce package of aseptic 
cotton for the navel dressing ; the child's clothing. 

Hand-brushes, scissors, cheese-cloths and the ligature for 



136 



ESSENTIALS OF OBSTETRICS. 



the funis should be wrapped in a towel and sterilized by 
steam or by boiling at the beginning of labor. They are 
kept enveloped in the towel until wanted for use. Similar 
care should be taken with all other appliances that other- 
wise might directly or indirectly be the source of infection 
to mother or child. 

Antisepsis. 

Antiseptic Agents. 

1. Dry heat at 284° F. — exposure in an oven for half 
an hour may serve for utensils. 

2. Boiling for ten minutes, or steaming for half an hour. 
Boiling is best done in water to which 1J per cent, of 
sodium carbonate, c. p. (washing soda), has been added. The 
soda removes greasy matter and tends to prevent metallic 
instruments from rusting, and boiling in the solution is a 
much more efficient germicide than boiling in plain water. 

3. Chemical antiseptics. 



Mercuric iodide solution, 1 : 2000. 

R . — Hydrargyri biniodidi j 
Potassii iodidi i 

Aquae* .... 

Mercuric chloride [sublimate) solution 
R. — Hydrargyri bichloridi 

Acidi tartarici . 

Aquae .... 

Chlorinated soda solution, 1 : 10. 
R . — Liquor sodae chloratae 

Aquae .... 

Creolin solution, 1 : 1000. 
R.— Creolin .... 
Aquae .... 



aa 



1 : 2000. 



gr. vijss. 
Oij.— M. 

gr. vijss. 
gr. xl. 
Oij.— M. 

^ix.— M. 



Sijss. 
Oij.— M. 



The water should previously he sterilized by boiling. 



PHYSIOLOGY OF LAB OB. 137 

Carbolic solution, 1 : 20. 1 

R.— Acidi carbolici) ^ z;~~ 

>-.... act ^jlSS. 

Glycerini i 

Aquge Oij . — M. 

Peroxide of hydrogen in full strength, or diluted with 
one or two or four volumes of water, is a useful antiseptic. 
It has the advantage of being non-poisonous. 

Practical Bides for Antisepsis. 

Non-metallic utensils may be disinfected with any of the 
foregoing agents ; heat is the most efficient. 

Metallic instruments are best sterilized by boiling in the 
If per cent, soda solution. Baking for ten minutes in an 
oven at a temperature a little below 300° F. is effective, 
but it injures the edges of cutting instruments. 2 

In sterilizing by steaming or boiling instruments may 
for convenience in handling first be wrapped in a towel. 

Cloths, bed-linen, etc., are best sterilized by steaming. 
Flowing steam is most active. Dry heat does not pene- 
trate dressings well. 

When the chemical solutions are used exposure for at 
least a half hour is desirable. 

The obstetrician should wear a sterilized operating-gown 
to cover his clothing and prevent contact of his hands and 
arms therewith. 

Technique of Hand- cleaning. 

(a.) Filrbringer method. 

1. The nails are kept short and cleaned dry. 

2. The hands and forearms are scrubbed thoroughly with 

1 Approximately. 

- The spores of the bacillus tuberculosis are killed by dry heat only after an 
exposure of three hours to a temperature of 2S4° F, 



138 ESSENTIALS OF OBSTETRICS. 

soap and hot water and a hand-brush for not less than five 
minutes, giving special attention to the finger-tips and the 
free edges of the nails and using two or three changes of 
water. 

3. The soap is rinsed off with sterilized water. 

4. The hands and forearms are held in one of the mer- 
curial solutions (1 : 2000) for five minutes. 

As an additional precaution the hands may be wet well 
with alcohol (80 per cent, or more) before immersion in the 
antiseptic solution. This helps to remove fatty matter and 
by dehydrating the skin makes the antiseptic sink more 
deeply. 

Hand-brushes should be steamed for ten minutes or boiled 
in the soda solution for the same length of time. 
(b) Permanganate method. 

Steps 1, 2 and 3 as in a. 

4. Immerse for two or three minutes in a warm saturated 
solution of permanganate of potassium in boiled distilled 
water, using plenty of friction. 

5. Remove the permanganate stain by immersing in a 
warm saturated solution of oxalic acid made with sterilized 
water. 

6. Rinse with sterilized water. 

7. Immerse for five minutes in a mercuric iodide or 
chloride solution, 1 : 500. 

With this method the hands may be rendered sterile to 
culture-tests. 
(<?.) Chlorinated soda. 

Steps 1, 2 and 3 as in a. 

Cover the skin with a paste made by wetting with boiled 
water a handful of fresh chlorinated lime. Rub the paste 
over the hands with a crystal of washing soda till it feels 
cold. Scrub well for five minutes with a sterilized brush. 



PHYSIOLOGY OF LABOR. 139 

Rinse with sterilized water, then with alcohol, and finally 
with the water again. This, too, yields sterile results. 
(d.) Boiled gloves. 

Prepare the hands as in a. 

Then put on thin rubber or lisle thread gloves which 
have been boiled for ten minutes. 

The gloves are especially useful when the hands are sore 
or have been recently exposed to virulent infection. 

After cleansing, to prevent reinfection of the hands, they 
must touch nothing that is not aseptic. They should be 
held for a moment in the mercurial solution before each 
internal examination. 

Lubricants. As a lubricant for the hands, either a 1 : 500 
solution of mercuric iodide in glycerin may be used, or they 
may be wet with the antiseptic solution. Keeping the hands 
smeared with the biniodized glycerin keeps the skin soft and 
maintains continuous disinfection. Glycerin recently steril- 
ized by heating to 212° F. for ten minutes may be used 
instead of biniodized glycerin as a lubricant. 

The nurse should wear wash dresses recently laundered, 
and should prepare her hands, as the doctor does, before 
contact with the genitals of the obstetric patient. 

The patient, at the onset of labor, is given a bath and a 
change of clothing. Before the internal examination the 
nurse cleanses the external genitals, the thighs, and abdo- 
men of the patient with soap and warm water for five min- 
utes; the soapy water is then removed and the parts gently 
scrubbed for five minutes with the antiseptic solution. 

In case of yellowish, greenish or fetid discharges the 
vagina and cervical canal should be prepared in like manner, 
cleansing with soap and water, using gentle friction, and 
finally with an antiseptic douche continued for at least five 
minutes, with friction. The object is prophylaxis, not alone 



140 ESSENTIALS OF OBSTETRICS. 

against infection of maternal wounds but also against oph- 
thalmia in the child. 

The antiseptic may be the chlorinated soda or the creolin 
solution. Mercurial irrigation if used at all should be fol- 
lowed after five or ten minutes with a plain sterilized water 
douche to wash out the chemical as a precaution against 
mercurial intoxication. A more satisfactory disinfection is 
effected by douching twice daily for a week or two before 
labor, when possible, with a mercurial solution or with a 2 
per cent, lactic-acid solution. 

It is well for the nurse, after carefully cleaning the ex- 
ternal genitals at the onset of labor, to apply a compress 
kept wet with Thiersch's solution, or a saturated boric-acid 
solution, to be worn during the first stage. 



Examination or Patient during Labor. 
Scheme. 

1. Verbal. 

Precursory signs of labor : 

Lightening ; 

Frequency of urination and bowel movements. 
Signs of actual labor : 

Increased frequency of urination and defecation ; 

Bloody discharge — the show ; 

Expulsion of mucous plug from the cervix ; 

Rhythmic pains, first felt in the lumbo-sacral then 
in the lower abdominal regions. 

2. Abdominal. 

Pendulous abdomen ; 
Hydramnios ; 
One foetus or two ; 
Location of placenta ; 



PHYSIOLOGY OF LABOR. 141 

Pathological growths; 

Presentation, position and posture of the fetus ; 
Foetal heart-tones, rate, rhythm, force ; 
Bladder, empty or not ; 
Hardness of the head ; 
Relative size of head and pelvis. 
3. Pelvic. 

Pudendum, rigidity, oedema, former injuries ; 
Vagina, mucosa healthy or not ? Secretion nor- 
mal or not ? Former injuries ? 
Rectum and bladder, full or empty ? 
Bony pelvis : diagonal conjugate and other di- 
ameters ; shape, inclination. 
Cervix, how much dilated ? Dilatable ? Former 

injuries ? 
Bag of waters, size, shape, ruptured ; 
Presentation, position and posture of foetus ; 
Caput succedaneum, how large? 
Stage of progress. 
In the internal examination vertex presentation is recog- 
nized by the hard and globular character of the head, and 
by tracing the sutures and fontanelles ; the position is made 
out by locating the sagittal suture and finding which end is 
forward ; the posture by noting the relative descent of the 
fontanelles ; the stage of progress, in the first stage by the 
extent of cervical expansion, in the second by the situation 
of the leading pole, occiput, as relating to the landmarks of 
the birth-canal. 

Examine deliberately all accessible foetal parts with deep 
pressure. Examination is best begun during a pain and 
continued into the interval. The frequency and strength of 
the pains and the general condition of the patient, including 
her pulse and temperature, should be observed. 

7* 



142 ESSENTIALS OF OBSTETRICS. 

The prognosis must usually be guarded: it should be 
made as definite as the findings permit. All else being 
normal the duration of labor will depend on the strength 
and frequency of the uterine contractions and the ability of 
the patient to help them by voluntary effort. 

Management of the Stage of Dilatation. 

Measures far relief of severe pain are chloral, in doses of 
gr. xv in water, every fifteen minutes, opium, gr. i. or an 
equivalent dose of morphine or codeine. Yet opiates should 
seldom be given and only in the event of great pain and 
restlessness. Chloroform, by inhalation, is very rarely per- 
missible in the latter part of the first stage. The use of 
chloroform at this time is almost certain to impair the effici- 
ency of the pains. Once begun it cannot easily be discon- 
tinued till the expulsion of the child, and prolonged chloro- 
form inhalation is a dangerous depressant. General anes- 
thesia should be withheld, therefore, until absolutely required. 

Vaginal examinations should be as infrequent as is con- 
sistent with a proper knowledge of the case. If a careful 
ante-partum examination has been made a single internal 
examination will usually be sufficient for the first stage of 
labor. Nothing so surely protects the parturient against 
infection as the avoidance of all internal interference. It 
is frequently possible to conduct the labor to its termination 
with no vaginal examination at all. 

Special directions. Active measures for accelerating the 
first stage are permissible only when indicated by danger to 
mother or child. It is a general rule to remain with the 
patient, or. at least, in the house, from the time the os 
externum has reached the size of a silver dollar. 

The patient must be advised not to keep the bed, not to 
bear down with the pains and to frequently empty the 



PHYSIOLOGY OF LAB OB. 143 

bladder and the rectum. The lower bowel should always be 
cleared once or more at the onset of labor with an enema 
of warm water. Instructions should be given with reference 
to diet. 

The maternal and the foetal pulse-rate are to be noted 
from time to time. A foetal pulse below 110 or above 150 
to the minute should be regarded as a signal of danger to 
the child. 

Management of the Stage of Expulsion. 

Taking the bed. The patient should take the bed when 
the second stage begins, sooner if the pains are severe or 
the membranes have ruptured. 

She should be dressed for the bed with her night clothing 
turned up and pinned at the shoulder, and with a clean 
folded sheet fastened about the waist like a skirt. The 
sheet serves the purpose of protecting the patient's clothing 
and the upper part of the body from soiling with the genital 
discharges. These precautions simplify the duties of the 
nurse in cleansing the patient at the close of labor. 

Rupture of the membranes. The bag of membranes if 
still unbroken, should be ruptured artificially when it reaches 
the pelvic floor. It may be torn with the finger-nail or 
punctured with a stout hairpin, previously flamed, or with 
a sharp-pointed scissors. The instrument is passed with its 
point resting on the finger as a guard and the bag punc- 
tured while tense, during a pain. 

Puller. Unless the labor is over-rapid, the patient may 
be permitted, during the pains, to pull upon a sheet twisted 
into a rope and fastened at one end to the foot of the bed. 
The use of the puller increases the efficiency of the voluntary 
expulsive efforts. 

Obstetric position. Generally the position may be left to 



144 ESSENTIALS OF OBSTETRICS. 

the patient. For internal examinations the dorsal re- 
cumbent position is best. At the perineal stage the posi- 
tion most favorable from the standpoint of both the mech- 
anism and the management is the lateral. Occasional 
changes of posture relieve fatigue and promote the progress 
of labor. 

Vaginal examinations should be infrequent. It will sel- 
dom be necessary to examine internally oftener than once 
an hour at the most. A single examination at the begin- 
ning of the second stage is usually sufficient. This is gen- 
erally desirable to make sure that the cord or a hand has 
not prolapsed and that no other irregularity is present. 
Once assured that all is normal, further interference within 
the passages is not only unnecessary but is injurious. The 
progress of labor while the head is passing the brim may be 
observed by palpation over the lower abdomen. After the 
head has sunk well into the pelvis the rate of descent can 
be watched by examining through the pelvic floor, with the 
finger on the skin surface near the posterior vulvar com- 
missure; by deep pressure at this point the head can be 
felt before it rests on the floor. By these means internal 
manipulations can be reduced to a minimum, and sometimes 
be wholly omitted. 

Anaesthesia. An anaesthetic, if properly administered, 
may be used with advantage in most labors during at least 
the latter part of the second stage. In obstetric anaesthesia 
the aim is to blunt the pain, not to abolish it. Here the 
anaesthetic is given for short periods and intermittently — 
with the pains only. At the moment of expulsion it may 
usually be carried nearly or quite to the surgical degree. 
As [a rule chloroform is preferred for mere obstetric anal- 
gesia. Ether should be chosen when complete anaesthesia 
is required for obstetric operations. Ether is equally appli- 



PHYSIOLOGY OF LABOR. 



145 



cable for partial anaesthesia in simple labor and by some 
obstetricians is preferred, but it is not so pleasant. 



Fig. 45. 




Giving chloroform with the towel inhaler and dropping-bottle. 

It is generally a good rule to withhold anaesthetics as 
long as the pains are well borne without them. The pro- 
longed and too free use of chloroform during labor is capable 
of serious injury to the mother. It must not be forgotten 



146 ESSENTIALS OF OBSTETRICS. 

that the strength of the uterine contractions is impaired by 
anaesthetics. 

Method. Have the head low and the clothing loose, re- 
move false teeth, examine the heart and protect the skin 
about the mouth and nose by smearing with vaselin or 
glycerin. A good inhaler is a towel spread over the head 
and lifted at its middle six or seven inches from the face. 
Ask the patient to breathe deeply when the pain begins. 
Drop on the towel opposite the mouth and nose one or two 
drops of chloroform at each breath. If ether is used, three 
or four drops at each respiration will be required. (Fig. 45.) 

Whatever effect is to be produced must be obtained before 
the pain reaches its height. Normally at the acme of the 
uterine contraction the abdominal muscles are fixed and 
respiration is temporarily suspended. 

Regulation of the expelling forces. If the pains are 
feeble they may be stimulated by simple means, such, for 
example, as postural measures. Summon the aid of the 
abdominal muscles. In over-rapid labor the pains may be 
moderated by the use of anaesthetics and by regulating the 
action of the voluntary muscles. Anaesthetics arrest or 
retard expulsion according to the freedom of dosage. Un- 
necessary manipulation of the cervix must be avoided; 
irritating the tissues lowers the resisting power and invites 
sepsis. 

Prevention of pelvic-floor lacerations. The chief reliance 
for preventing pelvic-floor injuries during the birth is a 
slow and gradual delivery of the head by its smallest 
diameters. Expulsion is to be retarded by anaesthesia and 
by the fingers held against the occiput. This permits the 
resisting structures to stretch. Not only the rate but the 
mechanism of expulsion must be regulated. Keeping the 
smallest circumference of the head in the grasp of the resist- 



PHYSIOLOGY OF LAB OB. 147 

ing girdle, press the head well up into the pubic arch as 
the forehead is about to escape. These measures reduce 
the strain on the soft parts. From the time the pelvic floor 
begins to bulge the birth of the head should rarely occupy 
less than a half hour. 

Shelling out the head between the pains, manipulations 
within the rectum and most similar measures that have 
been recommended for the prevention of so-called perineal 
ruptures, must be regarded as useless if not injurious. 
Supporting the pelvic floor by pressure with the hand is 
rational in so far as it crowds the head into the subpubic 
arch and thus relieves the tension of the fascial structures 
of the floor. 

Episiotomy . When much laceration is otherwise inevit- 
able incise the resisting ring at the introitus bilaterally. 
Cut while the ring is tense during a pain. Pass a straight, 
narrow blunt-pointed bistoury flatwise between the head 
and the cord-like girdle. Turn the cutting edge outward 
and cut horizontally, holding the knife parallel with the axis 
of the patient's body. The location of the cut should be 
one- third way from the median line posteriorly when the 
parts are fully stretched. The length of the incision should 
be about 1 inch, the depth J inch. The incisions are sutured 
after labor. 

Management of the cord. If coiled about the neck, slip 
the coils one by one over the head. Failing this, which 
is scarcely possible, cut the cord and deliver the trunk 
promptly. 

Delivery of the trunk. Hold the head well up toward 
the mother's abdomen and deliver the posterior shoulder by 
hooking a finger in the axilla and lifting the shoulder over 
the posterior commissure. Disengage the posterior arm 
and then release the anterior shoulder. Extract the trunk 



148 ESSENTIALS OF OBSTETRICS. 

slowly or leave its expulsion to nature. Powerful traction 
on the head should be avoided if possible owing to the 
danger of inducing Duchenne's paralysis by stretching the 
nerve-trunks of the brachial plexus. 

Ligation of the cord. As a rule, wait till notable pulsa - 
tion ceases or until the child cries lustily. By delaying 
the ligation of the cord for several minutes, till respiration 
is established, a gain of from one to three ounces of blood 
is effected, a matter of importance more especially in pre- 
mature and in puny or anaemic children. This postnatal 
afflux of blood is probably brought about by the force of 
thoracic aspiration in the child. 

Tie the cord firmly with aseptic narrow linen bobbin 1.5 
cm. (about J inch) from the umbilicus. A second ligation 
to control the placental end of the cord is required in case 
of twins ; in single births it is not necessary. Cut with 
surgically clean scissors 6 mm. (about J inch) outside the 
ligature. Press the end of the stump with a sterile cheese- 
cloth to see if it bleeds ; if it does tie again. A thick cord 
should be pinched firmly before tying to press out the jelly 
of Wharton from the part to be ligated. 

Management of the Placental Stage. 

From the moment the head is born the hand should be 
held on the abdomen over the uterus till evacuation and re- 
traction of the uterus are complete. Gentle friction may 
be used if required to promote normal contractions. 

Delivery of the placenta. Crede's method. When the 
placenta is not spontaneously expelled within thirty minutes 
after the birth of the child the uterine contractions are to 
be reinforced by the method of Crede. At the acme of 
the pain, not sooner, grasping the fundus through the ab- 
dominal wall with the thumb in front and fingers behind, 



PHYSIOLOGY OF LABOR. 



149 



compress the fundus firmly. (Fig. 46.) To the compres- 
sion should be added a moderate downward pressure in the 
uterine axis. To bring the uterine into line with the vaginal 



Fig. 46. 




Expressing the placenta by the method of Crede. 



axis carry the fundus well back during the manipulation. 
Repeat the process with each pain till the placenta is expelled. 
The cord should not be pulled upon to assist delivery till 
the placenta is in the vagina. 

Manual extraction. Crede failing after an hour, the pla- 
centa may be removed manually by seizing its lower edge 
with the fingers passed through the cervix. 

Management of the membranes. On expulsion of the 
afterbirth pull very gently on the membranes till they are 



150 ESSENTIALS OF OBSTETRICS. 

wholly detached. Should the uterus be contracted, wait till 
it relaxes lest a portion of the membranes still held in the 
grasp of the uterus be torn off and left behind. 

Examination of the placenta and membranes. The pla- 
centa and the membranes must be carefully inspected to 
make sure no fragments have been left in the passages. The 
membranes are best examined by transmitted light to see 
that both amnion and chorion are complete. When viewed 
in this manner a single membrane is quite translucent, both 
together somewhat opaque. Fragments of membrane wholly 
or partly in the vagina should be removed. When wholly 
in the uterus they are better left to be expelled with the 
lochial discharge. Manipulation within the passages, espe- 
cially within the uterus, at the close of labor, exposes to 
infection. 

Laceration of the Passages. 

Cervical lacerations must be closed immediately by suture 
in case they give rise to troublesome hemorrhage. Other- 
wise immediate suture is generally inadvisable. Spontane- 
ous union takes place, as a rule, in aseptic convalescence. 

Method of suture. No anaesthetic is needed. The patient 
is placed in the dorsal recumbent or lithotomy position on 
the bed or a table. The cervix is well drawn down with a 
volsella. The traction usually controls the hemorrhage for 
the time. The surfaces of the cervical wound are brought 
together and sutured with silk, the first stitch being passed 
above the angle of the tear. The sutures should be placed 
2 cm. (about f inch) apart. 

Lacerations of the pelvic floor. The frequency of pelvic- 
floor lacerations is in primiparse from 15 to 35 per cent., in 
multipara about 10 per cent. 

Causes are : Narrow pubic arch ; a relatively small 



PHYSIOLOGY OF LABOR. 151 

vulvo-vaginal orifice ; rigidity of the pelvic floor ; advanced 
age in primiparae — over thirty years ; faulty mechanism ; 
too rapid delivery ; unskilled use of forceps. 

Character of the injury. In the vast majority of cases, 
if not in all, the tear runs up into the vagina on one or both 
sides of the rectum, i. e., in one or both vaginal sulci. 
When the laceration is confined to one side it takes a nearly 
straight course, terminating below in the skin of the peri- 
neum and above in the vaginal mucosa. When the injury 
extends into both vaginal sulci the tear presents a Y-shape. 

Degrees of laceration. 1st. To the sphincter ani; 2d. 
Through the sphincter ani ; 3d. Into the rectum. 

Treatment, (a.) Time for repair. Lacerations at the 
vaginal orifice involving the muscular or the fascial struct- 
ures should, as a rule, be sutured at the close of labor. 
Union, however, may be obtained by suturing at any time 
within a week or more if the wound is aseptic. Suturing 
while waiting for the delivery of the placenta may save the 
necessity for renewed anaesthesia ; it is not advisable in ex- 
tensive or complicated tears. 

(b.) Suture material. For partly exposed sutures ster- 
ilized paraffined silk or silkworm-gut ; for buried sutures 
sterilized catgut is suitable. 

No. 7 silk is a good size for deep sutures. One or two 
sizes smaller may be used for shallow wounds. Common 
Corticelli sewing-silk of the dry goods stores, size F, or FF, 
is a satisfactory substitute for the usual surgical material. 
Silk may be sterilized and waxed at the same time by 
immersion for an hour in melted paraffin at a temperature 
of 284° F. A special thermometer that can be kept im- 
mersed in hot wax must be used for regulating the tempera- 
ture. The paraffin selected for the purpose should be soft 
enough to become plastic at the temperature of the hand. 



152 ESSENTIALS OF OBSTETRICS. 

Silk thus prepared is not only sterile but it is less absorbent 
and less likely to cause suppuration by leading septic matter 
into the needle track. Catgut may be prepared by Fowler's 
method, boiling for an hour in absolute alcohol. Silkworm- 
gut is boiled in water for ten minutes immediately before 
using. The same method answers for plain silk. Catgut 
put up in alcohol and sterilized in sealed glass tubes is espe- 
cially recommended. 

(c.) Needle. A slightly curved Hagedorn or other sur- 
gical needle, about two inches long, is suitable. Lange 
needles curved on the flat will be found satisfactory. Small 
and medium sizes are required. A common darning-needle 
will do in the absence of a better. It may be held in the 
fingers or in a needle-holder. 

(d.) Anaesthesia is generally required. Chloroform is 
usually safe for the purpose if managed properly. Ether 
is to be preferred. 

Slight tears may sometimes be sutured with the aid of 
cocain anaesthesia. The cocain solution should be boiled 
immediately before using. It is most eifective when injected 
at several points into the lips of the wound. Not more than 
a grain can safely be used in this manner. 

(e.) Operation. The patient is placed in the lithotomy 
position with the hips at the edge of the bed or table. The 
knees may be held by assistants, or with a Dickinson's sheet- 
sling, as follows : Holding a sheet by diagonally opposite 
corners twist it loosely into a rope ; with the patient in the 
required position pass the sheet sling under both knees, 
carry one end over her shoulder, across the back of the 
neck and over the other shoulder or under the arm to the 
front again ; pull taut and tie the ends together in front of 
the chest. 

Pack the vagina above the wound with sterilized strip 



PHYSIOLOGY OF LABOR. 



153 



gauze, to prevent the flow of blood over the field of opera- 
tion. Remember to remove the packing after placing the 
sutures. Press the wound surfaces with a sponge compress 
repeatedly till dry. Determine the character and extent of 
the injury. Tags of tissue that might become necrotic 
should be clipped oif with scissors. 

The aim should be to restore accurately the normal rela- 
tions of the parts. This may generally be promoted by 
catching the posterior vaginal wall with a volsella at what 
before rupture was the centre of its lower end, and lifting 

Fig. 47. 




Tear running up one sulcus ; sutures in sulcus tied ; crown stitch in place. 



this point nearly to the meatus urethras The trough-shaped 
wound on one or both sides of the vagina will thus be plainly 
displayed. The vaginal wall is held in the position described 



154 



ESSENTIALS OF OBSTETRICS. 



till the sutures are laid. The plane of each suture should be 
nearly parallel with the skin surface of the perineum. When 
the lacerations in the sulci are closed the remaining wound 
in the skin surface will be insignificant. It may be closed 
with a single crown (Fig. 47) or with two or three inter- 
rupted sutures. The stitches in the sulci should be placed at 
intervals of J inch, beginning at the upper or vaginal angle 
of the wound. Enter the needle close to the edge of the 
wound, give it a fairly deep lateral sweep through one lip, 
emerging just short of the bottom of the wound, and pass 
it in reverse direction through the other lip. Care will be 
needed to avoid passing the needle into the rectum. The 
loop after the suture is tied should be nearly circular. As 





$ 



Tear running up both sulci ; sutures laid in both. 



One sulcus closed. 



the sutures are laid the opposite ends of each are knotted 
together or held with catch-forceps till they are ready to tie. 
When the sutures are all placed tie them tightly enough to 
coapt, not to constrict, the wound surfaces, first removing 



PHYSIOLOGY OF LABOR. 



155 



the gauze packing and clearing the wound of blood-clots. If 
silk is used the ends are left 2.5 cm. (1 inch) in length to 
facilitate removal. (Figs. 48, 49, 50, 51.) 

Lacerations entering the rectum may be sutured on three 
sides — the rectal, the vaginal and the perineal or skin side 
(Fig. 52), or the rectal suture may be omitted and the rectal 





Both sulci closed ; crown stitch in place. 



All sutures tied. 



mucous membrane be closed with buried catgut. Bring the 
ends of the sphincter muscle together with two or three 
buried catgut sutures. (These are not shown in the figures.) 
When the sphincter is nearly or completely severed the posi- 
tion of each end of the torn muscle is marked by a depression 
on either side of the median line caused by retraction of the 
torn muscle. Draw out the ends with a tenaculum ; pass each 
suture through one end, carry it across and through the op- 
posite end. To relieve the buried sphincter sutures of too 
great strain they should be reinforced with one or two silk or 
silkworm-gut sutures as follows : Enter the needle from the 



156 



ESSENTIALS OF OBSTETRICS. 



skin surface one-fourth inch from the edge of the tear, carry 
it up through the lip of the wound, pass it across above the 
angle of the tear just short of the mucous membrane of 
the rectum and carry it symmetrically down through the 
opposite lip. (Figs. 51, 52.) 

Fig. 52. 




Tear entering rectum ; sutures laid in three series, one rectal, one vaginal and 
one from the skin surface. 



A running suture of catgut in two or three layers affords 
an excellent method of treating lacerations of the pelvic 
floor. Beginning at the upper end of the tear, in the 
vagina, the deeper third or half of the wound is closed by 



PHYSIOLOGY OF LABOR. 157 

a continuous suture running throughout the entire length 
of the laceration. The process is repeated once or twice 
until the entire wound is closed. 

Anterior or lateral tears of the vagina or of the vulvo- 
vaginal orifice should be sutured. 

Old lacerations sustained in a previous labor, and which 
have not been repaired, may sometimes be repaired to ad- 
vantage at this time. The method does not differ from that 
usually employed in the secondary operation. 

After-care. It is unnecessary to bind the knees together. 
The catheter is usually required for a time at least after 
suture of the pelvic floor. It should be omitted if possible. 
Care must be used to prevent the urine from trickling into 
the vagina or over the wound surfaces. The bowels are 
opened on the second day and once daily thereafter. The 
sutures are removed on the eighth or ninth day. 

Care of the Patient at the Close of Labor. 

Retraction of the uterus. For at least a half hour after 
delivery of the placenta the uterus must be watched, holding 
the hand over it upon the abdomen. Gentle friction is used 
if necessary to promote contraction. One or two doses of 
the fluid extract of ergot of a half drachm each are gen- 
erally required, especially when chloroform has been given. 
Ergot is useful as a prophylactic, not only against post- 
partum hemorrhage, but against puerperal infection, since 
it tends to prevent the formation and retention of blood- 
clots in the uterus. Moreover, by limiting the blood-supply 
it promotes involution. It may be administered by the 
mouth or subcutaneously. 

Cleansing. The nurse bathes the external genitals and 
soiled parts of the patient's body with sterilized water or 



158 ESSENTIALS OF OBSTETRICS. 

with a weak antiseptic solution, and changes her linen and 
bed-linen if soiled. Fresh boiled cheese-cloths, not sea- 
sponges, are to be used for bathing. Sea-sponges are diffi- 
cult to clean. 

Vulvar dressing. The external genitals are covered after 
cleansing with a dressing, the lochial guard. A folded 
napkin is commonly used. It should be sterilized by steam- 
ing or boiling and dried before using. 

Instead of the napkin a special dressing may be made of 
cotton, cotton-waste or other absorbent material loosely 
packed in a cheese-cloth envelope. It should be ten inches 
long, four inches wide and two inches thick. A tail- piece 
about ten inches long at each end of the pad serves for pin- 
ning to the abdominal binder. The pads are burned after 
using. 

Draw-sheet. This is a clean sheet folded to four thick- 
nesses. It is placed under the patient's hips to protect the 
bed, and changed as often as soiled. 

The abdominal binder is best made of a straight piece of 
unbleached muslin, a yard and a quarter long and half a yard 
wide. When applied it should reach just below the tro- 
chanters ; it ought to be moderately tight for the first twelve 
hours, subsequently looser. 

The binder is not indispensable, but the support it gives 
is usually grateful to the lying-in woman during at least the 
first few hours or days after labor. 

The condition of the mother, especially the pulse and the 
temperature, the amount of lochial flow and the firmness of 
the uterus, should be noted before leaving. 

Instructions to the nurse. The nurse should receive di- 
rections with reference to the care of the patient and par- 
ticularly in the matter of sleep, diet, evacuations of the 
bladder, nursing the child and watching the amount of 



PHYSIOLOGY OF LABOR. 159 

bloody flow. A drachm of the fluid extract of ergot may 
be left with the nurse to be given in the event of hemor- 
rhage, a grain or two of opium, or its equivalent, for use if 
required for severe after-pains, and a suitable antiseptic to 
be used in cleansing the genitals. All needed instructions 
should be given with reference to the care of the child. 
Within the first hour or two after birth the navel should be 
re-examined for possible bleeding. 



CHAPTEE IV. 

PHYSIOLOGY OF THE PUERPERAL STATE. 

COURSE AND PHENOMENA. 

Post-partum chill. Frequently a chill follows the birth 
of the child. It is due probably to the lessened heat- 
production incident to the abrupt cessation of the muscular 
efforts of labor and has no pathological significance. 

The pulse-rate. The pulse-rate as a rule falls shortly 
after labor below the usual standard. For a period of a 
week or more it may remain below 60, in exceptional in- 
stances as low as 40, to the minute. 

Temperature. The maximum physiological temperature 
for the first four or five days of the puerperium is 99 J°, 
thereafter 99° F. A rise of one or two degrees though 
common is not to be regarded as strictly physiological. 

Urination. Owing to lowered intra-abdominal pressure, 
to urethral spasm, to the bruised, swollen and sensitive con- 
dition of the structures about the urethra and to other 
causes, the patient is liable to retention of urine in the first 
few days following labor. The secretion is greatly increased 
after child-birth and over-distention of the bladder not in- 
frequently results. 

Peptonuria. Peptonuria is normal in the puerperal state, 
peptone being a product of uterine involution. 

Bowel movements. Sluggish action of the bowels is the 
rule. 



PHYSIOLOGY OF THE PUERPERAL STATE. 161 

Condition of the Uterus. The upper segment is thick 
and moderately firm. The lower segment remains thin and 
relaxed for about twelve hours after child-birth. Subse- 
quently it gradually regains its shape and firmness. 

The lymph-spaces or blood-channels are greatly enlarged, 
a condition favorable to resorptive activity and which con- 
stitutes one of the elements of septic danger in the lying-in 
period. 

The cavity. The deeper layer of the decidua remains to 
be shed piecemeal during the lochial flow. Shreds of the 
outer superficial layer, too, are retained to be loosened and 
discharged with the lochia. The placental site is slightly 
elevated above the general surface and is studded with small 
blood-clots lodged in the mouths of the vessels. The cavity 
at first contains blood and blood-clots and later its walls 
are smeared with a muco-sanguinolent fluid. 

Involution. Involution is the process by which the 
hypertrophied structures of the uterus and other genital 
organs are restored to the non-gravid condition normal to 
the parous woman. It is essentially a process of fatty de- 
generation resulting from the lessened blood-supply. The 
endometrium is wholly renewed. 

Uterus. The uterus at the close of labor measures 10 to 
12.5 cm. in width by 18 to 20 cm. in length, externally, 
(4 or 5 by 7 or 8 inches) ; the thickness of its walls is 2.5 
to 3.7 cm. (1 to 1J inch) ; the depth of the cavity is 

At the close of labor, about .... 15.0 cm. (6 inches.) 

" tenth day 10.7 " (4% " ) 

" second week 9.7 " (3% " ) 

" third week 8.8 " (Z% " ) 

fourth week 8.0 " (3% " ) 

After involution is complete the thickness, the width and 
the length of the uterus are approximately 1, 2 and 3 inches 
respectively. 



162 ESSENTIALS OF OBSTETRICS. 

It will be seen that in the parous woman the organ is 
somewhat larger than in the virgin state. 

The situation of the fundus at the close of labor is nearly 
midway between the umbilicus and the pubic bones ; a few 
hours later it is just above the umbilicus and the uterus is 
usually dextroverted ; by the tenth day, if involution has 
gone on normally, it is at the level of the brim. The height 
of the fundus, however, varies with the fulness of the blad- 
der and the rectum. 

The weight of the uterus at the termination of labor is 
about thirty-five ounces, at the end of the first week it is 
sixteen ; at the end of the second week, twelve ; and at 
the end of the third week, eight ounces. After involution 
is complete it weighs ten to thirteen drachms — one and a 
half ounce nearly. 

The duration of uterine involution is usually six weeks, 
but it frequently reaches eight or even ten weeks. 

Involution of the uterus is slower in non-nursing women, 
after twin births, premature labor, much hemorrhage, reten- 
tion of secundines, and is partially arrested in endometritis 
and by getting up too soon. It may be retarded by violent 
emotional disturbance. 

The cervix. The cervix is soft and shapeless, having an 
almost gelatinous consistence at the close of labor. Within 
twelve hours it begins to be gradually re-formed. 

The os internum is large enough to admit two fingers at 
the end of twenty-four hours. The os externum will admit 
one finger after seven to fourteen days. Involution goes on 
proportionately to that of the body of the uterus. The 
lower border is permanently notched to a greater or less 
extent in parous women. 

The vagina. The hypertrophied vaginal walls are much 
relaxed after labor. Their involution progresses with that 



PHYSIOLOGY OF THE PUERPERAL STATE. 163 

of the uterus ; the vagina is not wholiy restored to the nulli- 
parous condition, however. 

Other pelvic structures. The muscular structures of the 
pelvic floor, of the abdominal walls and all other structures 
which have undergone hypertrophy during pregnancy par- 
ticipate in the retrograde process and are partially or wholly 
restored to their ante-partum state. 

After-pains. Periodical uterine contractions continue for 
a few hours or days post-partum ; usually they are more or 
less painful in multipara owing to the greater relaxation of 
the uterus in women who have borne children and the con- 
sequent liability to retention of blood-clots at the close of 
labor. Generally they are not so in primiparse ; they ac- 
complish and maintain the retraction of the uterus and are, 
therefore, conservative when not too severe. Normally 
they cease altogether by the third or fourth day. After- 
pains are likely to be intensified while the child is nursing. 

The Lochia. The lochia are the genital discharges which 
follow labor. They are more or less bloody for four or five 
days, lochia rubra, and they contain shreds of decidua and 
of placental tissue ; then they become sero-sanguinolent, 
lochia serosa, for two or three days ; finally they are of a 
creamy appearance, lochia alba, and contain fat-granules, 
epithelial cells, leucocytes and cholesterin. For a week or 
more after labor their reaction is alkaline, then neutral or 
acid. The total amount is about three and a quarter pounds. 
The duration of the discharge is in normal cases from two 
to four weeks. 

MANAGEMENT OF THE PUERPERAL STATE. 

Post-partum Visits. As a rule the patient ought to be 
seen within twelve hours after labor, except when a com- 



164 ESSENTIALS OF OBSTETRICS. 

petent graduate nurse is in charge, and once or twice daily 
for the first three days ; once daily thereafter until the 
seventh is the rule in normal cases. Occasional visits 
should be made during the remainder of the post-partum 
month. 

The first visit. A systematic examination should be 
made at this and each succeeding visit. The general con- 
dition of the mother, the pulse and the temperature should 
be noted. Learn the amount and character of the lochia. 
The binder should be loosened and the uterus examined by 
the abdomen for size, firmness, tenderness. Observe in the 
abdominal examinations whether the bladder is over-filled. 
Learn if it has been evacuated and the quantity of urine 
voided. Inquire if the patient has had sufficient sleep and 
proper diet. The child should be looked after. Ascertain 
whether it has passed urine and meconium as evidence that 
the passages are pervious ; if there has been any discharge 
from the eyes or bleeding from the navel, and what the tem- 
perature is per rectum. 

Subsequent visits. Especially to be observed at the daily 
visits are the pulse, the temperature, the condition of the 
breasts, nipples, bladder, the amount and character of the 
lochia, the involution of the uterus and the general condition 
of the mother. The pelvic contents should be examined by 
the bimanual method once or more during the third or fourth 
week. Observe whether the introitus vaginae is normally 
closed, the vagina intact, the broad ligaments free from ex- 
udations or adhesions, whether the cervix is lacerated or 
gaping, and note the size, shape, position, deusity and 
mobility of the uterus. 

Too long continuance of the lochia is usually associated 
with some degree of sepsis in the uterine cavity. Persist- 
ence of the bloody flow in the third week, especially if 



PHYSIOLOGY OF THE PUERPERAL STATE. 165 

accompanied with sacral pain, should excite suspicion of 
retro-displacement of the uterus. 

The case should not be wholly dismissed until involution 
is complete and the pelvic organs are entirely restored to 
the normal non-gravid state. 

The condition of the child should be noted at each visit. 

Evacuations of the Bladder. Owing to the danger of 
over-distention the bladder should be emptied within six 
hours after labor and once in six or eight hours subsequently. 

Retention of Urine. Inability to void the urine may 
sometimes be relieved by hot fomentations over the meatus 
urethrse, a rectal injection of warm water, suprapubic press- 
ure and if need be a sitting or half-sitting posture during 
attempts at urination. After the first six or eight hours 
it is generally better to allow the patient to get out of bed 
to use a commode than to pass the catheter. When the labor 
has been unusually severe or the pelvic floor has been badly 
torn and been sutured the patient must constantly keep the 
recumbent posture for at least several days. 

Bowel Movements. The bowels are to be opened on 
the second or third day and once daily thereafter. For 
this purpose a simple laxative, an enema of warm water, Oj, 
or a saturated solution of Epsom salt, oj-ij. or a rectal in- 
jection of undiluted glycerin may be given. For internal 
use citrate of magnesium, the compound rhubarb pill, fluid 
extract of cascara or a cascara tablet is suitable. In case 
of hemorrhoids a quarter grain of the aqueous extract of 
aloes is recommended. 

After-pains. After-pains, if* severe enough to prevent 
sleep, may be relieved by one or two doses of opium, gr. J-j, 
by phenacetin, gr. v, or by chloral hydrate, gr. xx. The 
use of opium, however, should be avoided if possible. 

Restorative Measures. Restorative measures are rest 

8* 



166 ESSENTIALS OF OBSTETRICS. 

and sleep, as generous a diet as the patient can digest, 
tonics (iron, quinine and strychnine) and sometimes stimu- 
lants. It is especially important that the patient shall have 
several hours sleep shortly after labor. 

Antisepsis. Strict cleanliness of the patient's person, 
linen and bed-linen is imperative. 

The nurse should change the vulvar dressing every three 
to six hours during the first three days, and thereafter often 
enough to prevent the least putrefactive odor. The external 
genitals, their immediate surroundings and other parts of 
the body which may be soiled by the discharges, should be 
cleansed carefully with an antiseptic solution at each change 
of the dressing. Vaginal or uterine douches are to be used 
only in the presence of sepsis or of fetor not controlled by 
rigid external cleanliness. 

The nurse should be scrupulously clean. She should 
wear wash dresses, frequently changed, and be as careful in 
the observance of a strict asepsis as the doctor is required 
to be. 

Diet. The diet must usually be restricted to liquid or 
light solid food for the first day, often for a longer period 
if the patient is much exhausted or has taken an anaes- 
thetic. Milk, gruels, beef essence, animal broths, soft-cooked 
eggs, oysters, boiled custard, oat-meal mush or wheaten 
grits well cooked, dry toast and weak tea or cocoa are suit- 
able. After the first two or three days, in the absence of 
exhaustion, fever, indigestion or loss of appetite, a moder- 
ately full diet may generally be permitted. Convalescence 
goes on more rapidly under proper feeding. Either excess 
or too great restriction in the matter of diet must be avoided. 
Pains must be taken to adapt both the quality and the 
quantity of food to the needs of the individual patient. 

Subinvolution of the Uterus. Useful measures for 



PHYSIOLOGY OF THE PUERPERAL STATE. 167 

promoting involution are the following : Gentle friction 
applied for ten minutes, twice daily, with the hand on the 
abdomen ; the abdominal wall is moved in a circular direc- 
tion over the uterus ; galvanism may be used, ten to twenty 
milliamperes, one electrode over upper part of the sacrum, 
one upon the abdomen over the uterus, sitting ten minutes 
twice daily ; faradism, applied in like manner, is still more 
effective. Extract of ergot, gr. j, t. i. d., is useful. A hot 
vaginal douche, two or three gallons, temperature 115° F., 
once or twice daily, yields good results. Curetting is indi- 
cated in case of hypertrophied decidua. This and other 
measures to combat sepsis of the endometrium are required 
when the subinvolution is of septic origin. 

Active interference is not called for in slight departures 
from the normal rate of involution. Here all that is needed 
is a little longer period of rest than is the rule in strictly 
normal conditions. 

Use of the Catheter. Catarrh of the vesical neck fre- 
quently results from infection carried on the catheter. 
Catheterism, therefore, should be withheld, if possible, and 
when required should conform to the following rules : 

The instrument, if to be used by the nurse, should be a 
soft-rubber catheter. The catheter is boiled for ten minutes 
immediately before using, and after sterilizing must be 
handled only with surgically clean hands. 

The patient lies on the back with the knees drawn apart. 
She or an assistant retracts the labia to fully expose the 
meatus urethrse and holds them apart until the catheter is 
passed. 

The meatus and its surroundings are carefully cleansed 
and disinfected. 

The catheter, lubricated with sterilized vaselin, is passed 
4 cm. (about 1J inch), or till the urine begins to flow. 



168 ESSENTIALS OF OBSTETRICS. 

The urine is collected in a cup or small bowl. The evacu- 
ation of the bladder is repeated every eight hours. Care 
should be taken to prevent the entrance of urine into the 
vagina and its contact with genital wounds. The instru- 
ment is cleansed carefully after using. 

Regulation of the Lying-in Period. 

First tveek. The patient keeps the bed. As a rule, 
after the first few hours she may assume a half-sitting 
position, if necessary, for evacuation of the bladder or 
bowels. 

Second week. She maintains a recumbent posture on 
the bed or lounge ; may sit up in bed during meals and for 
urination and for bowel movements. 

Third week. She sits up in a chair all or part of the 
day. 

Fourth week. The patient has the liberty of the room ; at 
the end of a month, if all goes well, she can leave the room. 

The duration of the lying-in, however, must obviously 
vary according to the rate of uterine involution and the 
general progress of convalescence. 

LACTATION AND NURSING. 

Colostrum is the thin, slightly viscid, yellow liquid fur- 
nished by the mammary glands of the puerpera before the 
true milk secretion begins. It contains epithelial cells, fat- 
globules and certain bodies called colostrum corpuscles and 
is rich in proteids and saline matter. To the latter are as- 
cribed by some authorities its moderate laxative properties. 
Normally no colostrum corpuscles should be found in the 
milk after about the tenth day. 



PHYSIOLOGY OF THE PUERPERAL STATE. 169 

The true milk secretion is usually established by the 
third day in priuiiparge, the second in multipara. 

Signs of deficient lactation are : Mother's breasts per- 
sistently flabby, child not satisfied and showing signs of in- 
anition. The milk may be at fault in quality or in quantity. 
Clinically the best evidence of the amount and character of 
the milk secretion is to be had by noting whether the infant 
gains normally in weight. The average gain is five or six 
ounces per week for the first five months, and a pound 
monthly for the remainder of the first year. The child's 
weight should be taken weekly. 

The secretion is at fault in quantity, quality, or both, in 
from 10 to 20 per cent, of mothers. 

Measures for increasing the secretion. Generous diet, 
milk, tonics, especially strychnine, and attention to hygiene 
are the best galactagogues. Milk may be taken as a part 
of each meal, not as an addition to the usual feeding. Used 
in this manner it is generally well borne. Faradism applied 
directly through the breasts, once or twice daily, may help. 
Malt liquors and drugs of supposed galactagogue properties 
are of no real value. 

Care of the breasts and nipples. The nurse should 
cleanse the nipples after each nursing with a bland antiseptic 
solution, such as a saturated aqueous solution of boric acid 
to which one-eighth part of glycerin has been added. It is 
w T ell to cleanse the child's mouth in like manner before 
nursing. Excessive nursing must not be permitted. The 
nipple is injured by long-continued maceration. 

Gentle massage of the breasts may be useful in simple 
milk engorgement ; it should be prohibited in inflammation. 

Painful distention of the breasts may be relieved by 
saline cathartics and partial abstention from liquids, and by 
the use of the compression binder. 



170 ESSENTIALS OF OBSTETRICS. 

Contra-indications to suckling the infant. Among the 
conditions which should prohibit nursing are recent syphilis 
if the child is not infected, tuberculosis, marked anaemia, 
epilepsy, poor quality or very deficient quantity of milk, 
pregnancy. 

THE CHILD. 
Condition at Birth. 

Weight. The weight of the newborn infant is from 3175 
to 3288 grammes (7 to 7 J pounds), males weighing more than 
females by about a quarter of a pound, and first less than 
subsequent births. 

A loss of weight takes place during the first three days, 
amounting to six or eight ounces. Normally the child re- 
gains its initial weight by the end of the first week. The 
birth-weight is doubled at five months and trebled at 
fifteen. 

Measurements. See page 62. 

Temperature. The temperature ranges from 98.6° to 
99° F., but is easily influenced by slight causes. Consider- 
able elevation of temperature is frequently observed in 
innutrition of newborn infants. 

Circulation. The pulse-rate ranges from 120 to 140 per 
minute. The ductus arteriosus, the ductus venosus and the 
umbilical vein are obliterated in a week or ten days. The 
foramen ovale generally closes within the same period. 
Sometimes the upper part remains permanently open. The 
umbilical arteries are obliterated in their upper portions 
within five days, the lower parts remaining open to form the 
superior vesical arteries. 

Respiration. The respiratory tract is devoid of air till the 
first respiratory effort, and the lungs are therefore collapsed. 
The air-tract may contain blood and vaginal mucus drawn 



PHYSIOLOGY OF THE PUERPERAL STATE. 171 

into it by premature efforts at respiration. The first re- 
spiratory movement is due in part to air-hunger from arrest 
of the maternal supply of oxygen, and in part to reflex 
contraction of respiratory muscles excited by contact of air 
with the moist surface of the skin. The average rate of 
respiration in the newborn infant is 45 per minute. 

Skin. The skin of the child's back and of the flexor sur- 
faces of the limbs is more or less thickly covered with a 
cheesy coating, the vernix caseosa, which consists of fatty 
matter, epidermal scales and sebaceous material. The epi- 
dermis is partly exfoliated in the first two or three days, 
leaving the skin red and irritable. 

Bowels. The contents of the intestines, meconium, con- 
sist of intestinal secretions and bile, together with lanugo 
and epidermal scales derived from swallowed liquor amnii. 
The meconium is passed off and the stools become feculent 
within the first three or four days. 

Genito-urinary organs. The bladder usually contains 
urine at birth. The specific gravity of the urine is 1005 
to 1010, Albumin and sometimes sugar are present. Uric- 
acid deposits, simulating blood stains, are often observed on 
the napkin. 

In boys both testicles have descended into the scrotum. 
The preputial orifice is usually too small to permit easy re- 
traction of the foreskin. The prepuce is normally adherent 
to the glans in the newborn ; sometimes it requires to be 
stripped back by freeing the adhesions when the latter are 
abnormally firm. 

Nervous system. The nervous system is much more 
irritable and the nerve-centres more unstable than in later life. 

Special senses. The sensibility of the skin is feeble at 
birth, but it is fully established within the first day or two. 
The taste is sensitive to strong impressions. 



172 ESSENTIALS OF OBSTETRICS. 

The newborn infant is deaf at birth, since the meatus is 
closed and the middle ear devoid of air. Loud sounds are 
audible within a few hours. The retina is sensitive to light. 

Secretions. The lachrymal and the sweat glands are 
not, as a rule, developed in the first few months. Little or 
no saliva is secreted. The amylolytic function is absent or 
feeble for several months. 

Caput succedaneum. The caput succedaneum usually 
subsides within twenty-four hours, and the distortion of the 
head from moulding disappears in the course of two or three 
weeks. 

Management of the Newborn Child. 

Respiration. To inflate the lungs, provoke deep inspi- 
rations by blowing upon the face, by dashing a few drops 
of cold water upon the face and chest, or by gentle flagella- 
tion. Suspending the child by the feet promotes drainage 
from the respiratory tract and at the same time the flow 
of blood to the brain. 

Asphyxia Neonatorum. Asphyxia in the newborn 
infant is generally the result of injuries sustained during 
birth. Compression of the cord, premature separation of 
the placenta, pressure upon the foetal head in prolonged 
and difficult labors and especially in forceps operations, are 
among the most common causes. The prognosis varies with 
the degree of asphyxia. It is generally good in the cya- 
notic and grave in the pallid stage. 

Treatment. Preparatory measures. Clear the mucus 
from the throat with the finger wrapped with a wet soft 
linen, or, better, by aspiration with a soft-rubber catheter. 
In marked venous congestion one or two drachms of blood 
may be allowed to flow from the cord. If the child is pale 
and collapsed a rectal injection of water, at a temperature 



PHYSIOLOGY OF THE PUERPERAL STATE. 173 

of 105° to 108° F., should be given. Suspension by the 
feet is useful. The normal temperature is best maintained 
by keeping the child's trunk and lower extremities for the 
larger part of the time immersed in water at 98J° F. 

Direct insufflation. The child is laid upon its back ; the 
head is partially extended by placing a fold of blanket 
under its neck ; the face is cleansed and covered with a 
clean towel. To prevent inflation of the stomach the hand 
is held firmly on the epigastrium. With the mouth against 
the towel directly over the child's mouth the operator expands 
its lungs by breathing gently into them. This is repeated 
sixteen to twenty times per minute as long as the heart beats. 

Schultzes method. Suspend the child by the shoulders, 
face from the operator, holding a thumb in front and two 
fingers over the posterior aspect of each shoulder with an 
index finger caught in each axilla — inspiration. The press- 
ure of the thumbs should be relaxed to assist inspiration. 

Invert the position by swinging the trunk and lower 
limbs upward and toward the operator's face, flexing the 
body in the lumbar region — expiration. 

In feeble infants this method must be used with great 
caution, if at all, owing to the shock involved. This and 
direct insufflation are the most effectual methods for the 
resuscitation of stillborn infants. 

Sylvester s method. Place the child in a supine position, 
with the head well extended by a fold of blanket under its 
neck. For inspiration draw the arms well above the head. 
For expiration place them by the sides and gently com- 
press the thorax. 

Byrd's method. The child is held supine upon the hands 
of the operator at right angles to the forearms. For inspi- 
ration the radial borders of the hands are lowered ; for 
expiration they are raised. 



174 ESSENTIALS OF OBSTETRICS. 

Faradism. A weak faradic current may be employed 
when the respiratory movements are persistently feeble; one 
pole is applied to the nuchal region and the other over the 
epigastrium. 

Labordes method. Intermittent traction on the tongue. 

Incubation. An infant prematurely born will generally 
require to be kept in an incubator for the first month or 
more. It should be removed from it only for feeding or 
bathing. The temperature in the incubator should at first 
be about 90°, and gradually be lowered to that of the room 
during the few weeks preceding the final removal of the 
child. A thermometer is kept in the compartment with the 
child. Ample ventilation must, of course, be provided for. 

Rectal Injection. It is well to order a rectal injection 
of a tablespoonful of warm water to be given soon after birth 
as a means of detecting at once possible occlusion of the 
rectum — atresia ani. 

Bathing. The face is bathed on birth of the head and 
the eyes are cleansed and carefully dried as a prophylactic 
against ophthalmia. The instillation of a drop of Crede's 
solution (nitrate of silver, gr. x ad. Sj) is the rule in hos- 
pitals and may be practised in private cases. It should not 
be omitted in family practice when there is reason to suspect 
that the secretions of the birth-canal are infectious. 

The body is smeared with sweet oil or vaselin to facilitate 
the subsequent removal of the vernix caseosa. 

For the first few months the full bath may best be given 
by immersion. A morning hour should be chosen midway 
between feedings. The temperature of the water should be 
98° F. by the bath thermometer; that of the room, 75° F. 
The least chilling is injurious. 

The duration of the bath should not exceed five minutes. 
From the standpoint of asepsis a soft, fresh-boiled cheese- 



PHYSIOLOGY OF THE PUERPERAL STATE. 175 

cloth is preferable to a sea sponge. Only a bland, mildly 
alkaline soap (castile) should be used, and little of that. 
Special attention should be given to the scalp. The full 
bath is repeated daily in the summer, daily or every other 
day in the colder months. Parts of the body exposed to 
soiling must be cleansed as often as soiled. 

In puny and anaemic children the full bath is best post- 
poned for several hours or days. A partial sponging, or 
anointing daily with sweet oil or vaselin, may be substituted. 
Infant powder is generally unnecessary. 

Navel Dressing. The stump of the navel cord is 
dressed with dry sterile absorbent cotton ; turn to the left 
side to avoid injurious pressure on the liver, and retain by 
a loose abdominal binder. Rapid desiccation is the chief 
reliance for preventing putrefactive changes in the stump, 
and the dressing should be ordered accordingly. Powders 
tend to hinder the drying, and are best omitted. 

The cord must be dried and the dressing renewed after 
each bath ; or, after the first bath, anointing with sweet oil 
may be substituted for bathing till the cord falls. This 
usually occurs about the fifth day. 

It is imperative that the navel wound be kept surgically 
clean. Septic infection of the navel may result in umbilical 
phlebitis, pyemia and death. 

Clothing. For the first half-year or more the following 
is recommended : 

1. Napkin of cotton or linen diaper. 

2. An undershirt of the softest flannel, without sleeves, 
and opening in front. 

3. A fine flannel princesse dress with high neck and long 
sleeves, opening in front, and about twenty-five inches in 
length. 

4. A muslin slip of similar style. 



176 ESSENTIALS OF OBSTETRICS. 

5. Woollen socks long enough to reach to the knees. 

During the night the socks may be removed and the 
muslin and the flannel slip be replaced with a light flannel 
night-dress. 

The belly-band and all bands in the clothing should be 
loose enough to admit two or three fingers underneath 
them. The belly-band should be discarded after the navel 
heals. In all seasons the skin should be protected with 
woollen undergarments and the extremities should be as 
warmly covered as other parts of the body are. No garment 
ought to be worn till laundered. 

Nursing. The child is put to the breast after the mother 
has recovered from the shock of labor, usually within from 
eight to twelve hours. Ten to fifteen minutes may suffice 
for each nursing. 

The usual frequency is once in four hours for a day or 
two, then every two hours. The milk becomes too rich with 
too frequent nursing, too thin with too long intervals. One 
interval in the night is lengthened to four or six hours. It 
is well to wake the child, if necessary, on the hour. The 
intervals should be extended to three hours by the time the 
child is three months old. As a rule, one or more artificial 
feedings daily will be required after the seventh or eighth 
month. 

Wet-nursing. A good wet-nurse should be of mature 
age, below thirty-five, and preferably a multigravida. Her 
child ought to be of the same age as the foster child within 
one or two months. A menstruating woman is sometimes 
unsuitable, a pregnant one always. Sound physical and 
mental health is indispensable. She should be examined 
especially for tuberculosis, syphilis and other contagious 
diseases. The breasts should be of somewhat conical form, 
well developed, with prominent veins and well formed and 



PHYSIOLOGY OF THE PUERPERAL STATE. 177 

healthy nipples. The condition of the nurse's child speaks 
for the quantity and quality of her milk. 

Weaning. The time for weaning, as a rule, is after the 
child has cut eight teeth, except when that period falls in 
the hot months. 

Evacuations of the Bowels and Bladder. In health 
the number of bowel movements is from two to four daily. 
Urination is repeated every one to four hours. 

Sleep. The newborn infant requires eighteen to twenty 
hours' sleep out of the twenty-four. 

Artificial Feeding and Infant Dietary. 
First Twelve Months. 

The natural food of the infant for the greater part of the 
first year is milk. Milk, therefore, is the best substitute 
food for at least the first eight or ten months of life. Dur- 
ing this period farinaceous preparations should be excluded 
from the infant dietary. Newborn infants who thrive on 
farinaceous food do so in spite of the feeding, not because 
of it. The best practicable substitute for breast milk is a 
modified cow's milk. The average percentage of albuminoids, 
fat and sugar in cow's milk is approximately 4 for each, 
while in human milk the corresponding percentages are 
1 to 2, 3 to 4, and 7. It is obvious that cow's milk which 
has been merely diluted with water is a very imperfect sub- 
stitute food. The animal product must be so reconstructed 
that the resulting proportions of the principal nutritive 
ingredients shall conform as nearly as possible to those of 
human milk. The following formula fulfils this require- 
ment : 



178 ESSENTIALS OF OBSTETRICS. 

1. The Rotch-Meigs or Milk and Cream Mixture. 

Cow's milk — mixed dairy milk . . . ^ij. 

Cream, containing 20 per cent, of fat 1 . . ^iij. 

Water, previously boiled .... ^x. 

Milk sugar (recrystallized and perfectly pure) 3yj, gr. xlv. 

Lime-water 2 3J. 

The plain milk 3 mixture, or the condensed milk mixture 
given below, is sometimes well borne by robust children, yet 
they differ essentially in composition from breast milk. 
This is especially true of the condensed-milk mixture. The 
latter is nevertheless frequently of service, particularly for 
temporary use during the hot months, since it is practically 
sterile and keeps well. Usually either of these prepara- 
tions should be diluted for the first two or three months 
with three to five ounces of water more than the formula 
prescribes. 



2. Plain milk mixture. 








Cow's milk — mixed dairy 


milk 


• Ix. 




Water, previously boiled 




• ifv. 




Milk sugar 




■ 3yj, gr. 


xlv. 


Common salt . 




. gr. viij. 




Lime-water 


• 


• Eh 




3. Condensed milk mixture. 








Canned condensed milk . 




■ 3J- 




Boiled-water 




. • 3*. 




Cream . . . . 




. 3x. 




Salt . 




. gr. viij. 





The sweet brands of condensed milk are not objection- 
able merely on account of the proportion of sugar they con- 

1 Best, that obtained by the centrifugal machine, since it may be had fresh. 

- The addition of lime-water is essential, since cow's milk is feebly acid, 
human milk alkaline. 

3 The following is a simple test of the freshness of milk. Good milk, of 
average richness, at a temperature of 132° F., coagulates in three and a half to 
four minutes under one part of commercial rennet diluted with one thousand 
parts of water. Milk that coagulates in less than two minutes is unfit for use. 



PHYSIOLOGY OF THE PUERPERAL STATE. 179 

tain. Food prepared from canned condensed milk by the 
foregoing formula is not. as sweet as human milk, but the 
cane-sugar which has been added for the preservation of 
the milk is inferior to milk-sugar for infant feeding, since 
it is more prone to the butyric acid fermentation. Care 
must be taken to procure a milk that has not been too long 
kept or badly packed. 

Mixture 1 or 2 should be prepared, bottled and Pas- 
teurized shortly after the milk is delivered, in quantity 
sufficient for the day's consumption; mixture 3 may be made 
fresh immediately before using. 

Method of Pasteurizing. Ten clean bottles 1 are filled 
to the shoulders, each holding enough for a single feeding. 
The necks are then plugged lightly with rubber stoppers. 
Warm the bottles by immersion for a moment or two in 
water at a temperature a little above 100° F. Then stand 
in a suitable vessel, and pour enough boiling water in the 
vessel to cover the bottles to the necks. The contents of 
the bottles are thus brought approximately to the required 
temperature. After a half-hour push the stoppers in 
tightly, remove the bottles from the water and transfer to 
the refrigerator for rapid cooling. The same object may 
more surely be accomplished by keeping the milk for a 
half-hour at a temperature of 167° F. by the thermometer 
and then chilling. 

A convenient method of partial sterilization or Pasteur- 
izing consists in rapidly raising the milk to the boiling- 
point and then quickly chilling. 

Milk may be Pasteurized by heating in the open chamber 
of an Arnold's sterilizer. With the cover left off the tem- 
perature of the steam-chamber remains at about 170° F. 

1 Or as many as the number of daily feedings. 



180 



ESSENTIALS OF OBSTETRICS. 



Since about an hour is required to bring the milk to the 
temperature of the chamber, bottles should remain in the 
steam-chamber for an hour and twenty minutes. Milk 
treated by either of these processes and promptly chilled 
remains sufficiently sterile for practical purposes for at least 
twenty-four hours and it is saved the injurious chemical 
changes induced by prolonged exposure to temperatures 
above 167° F. Pasteurization has practically replaced full 
sterilization of milk for infant feeding. 

Feeding. The food is to be fed at a temperature of 96° 
to 97.5° F., and directly from the bottle in which it was pre- 
pared. The child nurses from a rubber nipple slipped over 
the neck of the bottle. The nipple must be boiled for ten 
minutes before using, and the bottles before filling. Both 
are carefully cleansed after using. 

Amount and Frequency. 



Age. 



First day . 
Second day 
Third day . 
Second week 
Six weeks . 
Three months 
Six 
Tsine 
Twelve " 



Intervals 


Amount 


Number 


of 


at eacn 


of daily 


feeding. 1 


feeding. 2 


feedings. 


2 hours 


1 drachm 


10 


2 


% ounce 


10 


2 


1 


10 


2 


iy z " 


10 


2^ " 


2% ounces 


8 


3 


3^ •' 


7 


3 


5% " 


6 


3 


6% " 


6 


3^ " 


9 


5 



Average 

daily 
amount. 

10 drachms 
5 ounces 
10 
15 
20 

24^ " 
33 

40^ " 
45 



Small or feeble children should be fed more frequently 
and in smaller quantities, larger children less frequently 



1 Lengthen one interval in the night to four or six hours. 

2 By measuring-glass. 



PHYSIOLOGY OF THE PUERPERAL STATE. 181 

and in larger quantities than the foregoing table provides. 
The daily allowance for the individual case must be learned 
by trial. The stomach capacity at birth is approximately 
yJpjj the body-weight of the child. As a rule it is an 
ounce for the first week and increases by a drachm and a 
half per week during the first five or six months. After 
that age the rate of increase is somewhat smaller. The 
weekly weight of the child is a good guide in regulating 
the feeding. As already stated, a properly nourished child 
gains at least five ounces weekly during the first five 
months. For the remainder of the first year the gain is 
about a pound per month. The birth-weight is doubled at 
five months and trebled at fifteen. 

Some farinaceous material, such as barley or oatmeal 
gruel, may be added to the food with advantage by the 
tenth month. The proportion of gruel may be one-eighth 
part of the entire feeding. 

Undiluted cow's milk mixed with barley or oatmeal gruel 
and Pasteurized is frequently well borne by healthy chil- 
dren after ten months. 

Feeble Digestion. 

If the casein coagulates in hard masses in the stomach, 
as shown by vomiting large firm curds, the trouble may 
sometimes be relieved by dilution of the food with plain 
water. 

A little pepsin with each feeding is frequently useful. 
The glycerite of pepsin is an eligible preparation for the 
purpose. The cold peptonizing process with pancreatic 
extract and soda may sometimes be used to advantage. 

When stronger foods are not well borne a whey and cream 
mixture may be substituted for a time. This is prepared as 
follows : 

9 



182 



ESSENTIALS OF OBSTETRICS. 



Whey and cream mixture : 
Whey 
Cream 
Boiled water 
Lime-water 
Milk-sugar 
Salt . 



3>iv. 
3iv. 

gr. v. 



To prepare the whey add a grain or two of pepsin dis- 
solved in a teaspoonful of water to a pint of milk at the 
temperature of 115° F. After the curd separates strain off 
the whey. 

Milk Laboratories, 

A recent advance in infant-feeding which has met with 
gratifying success in some of our larger cities is the milk 
laboratory. The physician writes a prescription for the 
food mixture very much as he does for medicine. The pro- 
portions for the essential ingredients in the formula, albu- 
minoids, fat, and sugar, are adjusted to the requirements of 
the individual case. The food mixture supplied daily from 
the laboratory is prepared according to the prescription, which 
is modified by the physician as occasion requires. 

The following formula, suitable for a healthy, full term 
infant, one week old, illustrates the method of prescribing. 

H . -Albuminoids 0.75. 1 

Fat 2.00. 

Milk-sugar 5 .00. 

Lime-water 5.00. 

Mix. Sterilize at 167° F. 

Send 10 bottles of 1J ounce each. 

In weak albuminoid digestion the proportion of albu- 
minoids is reduced to the minimum, 0.20 per cent., and 
gradually increased to the point of tolerance. A like modi- 



1 The numerals in the formula represent percentages. It is understood that 
the rest of the 100 parts is made up with water. 



PHYSIOLOGY OF THE PUERPERAL STATE. 183 

fication is prescribed in case of the fat or the sugar should 
either of these and not the proteid element be found to be 
the source of the digestive disorder. 

The following table shows the quantities of food and the 
percentages of albuminoids, fat, sugar, etc., required at 
different periods of the first year, as deduced from the ex- 
perience of the milk laboratories of New York and Boston. 



Age. 



Premature infants . 
Full term healthy infants 

1 week 

2 weeks 

3 " 

1 month 

2 months 



Stomac 
capaci 


;h Albumin- 
ty. oids. 


Fat. 


Sugar. 


2-6 dra 


as. 0.20-0.50 


1.00-1.50 


3.00-5.00 


1 


z. 0. 75 


2.00 


5.00 


IY2' 


1.00 


2.50 


6.50 


2 ' 


1.00 


3.00 


6.50 


2%< 


1.00 


3.50 


7.00 


3%' 


1.25 


4.00 


7.00 


4 ' 


1.50 


4.00 


7.00 


4K' 


1.75 


4.00 


7. CO 


5 ' 


2.00 


4.00 


7.00 


5K' 


2.25 


4.00 


7.00 


6 ' 


2.50 


4.00 


7.00 


ey 2 ' 


2.75 


4.00 


7.00 


7 ' 


3.00 


4.00 


6.50 


■%' 


3.50 
Perhaps 


4.00 
some cere* 


5.50 
il jelly 


8 ' 


4.00 


4.00 


4.00 


sy 2 i 


' Cow's milk 







Lime- 
water. 



5.00 

5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 
5.00 

5.00 



Twelve to Eighteen Months. 

The child may take four or five feedings daily of whole 
milk, with barley or oatmeal gruel or bread jelly in the 
proportions of one of the latter to seven of the former, and 



184 ESSENTIALS OF OBSTETRICS. 

Pasteurized. Two or three ounces of uncooked beef-juice, 
moderately seasoned, may be given daily ; it may be mixed 
with the milk or be given separately. It must be prepared 
at least twice a day and kept on ice. Care must be taken 
that the beef is fresh. 

After the child has sixteen teeth the simpler kinds of 
food requiring mastication may be added, such as oatmeal 
and milk, or wheaten grits, thoroughly cooked, or stale 
bread and milk. Scraped beef or soft-boiled eggs can be 
allowed two or three times weekly. 

Eighteen Months to Two Years. 

The number of feedings may be four or five daily. A 
little fine-cut meat, such as tender beef, lamb or chicken, 
may be added to the midday meal if the child is robust. 

Milk should be the chief reliance for feeding till the 
child has all its teeth and may constitute a part of its food 
for several years longer. Milk, beef -juice and the fari- 
naceous preparations above mentioned afford an ample 
dietary for the entire period of infancy. Proprietary foods 
for infants are not to be recommended. 

DISORDERS OF THE NEWBORN INFANT. 

Constipation. 

Treatment. Regulate the digestion and the feeding. 
Enough cream may be added to the food to raise the pro- 
portion of fat to 4, 5 or 6 per cent. This alone frequently 
overcomes the constipation in bottle-fed infants. Even a 
moderate excess of fat, however, is not in all cases well borne. 

Suitable laxatives are the following : 

R. — Sodii phosphatis gr. x. 

Sacchari lactis gr. x. — M. 



PHYSIOLOGY OF THE PUERPERAL STATE. 185 

This may be given at one dose in a teaspoonful or two of 
water or of syrup of manna. 

R.— Ext. sennse fluid, deoclorat. (N. F.) . . ^ss. 
Potassii et sodii tartratis . . . . 3j- 

Glycerini £ss. 

Aquse ad ^iv.— M. 

Dose, a teaspoonful, p. r. n. 

Phillips' milk of magnesia is an eligible laxative for 
infants. The dose is a teaspoonful. 

Useful rectal measures are the injection of equal parts of 
glycerin and water, 5\j, sweet oil, 5iv, or warm water, Sj. 
The use of a suppository of soap or cacao butter or a 
glycerin or gluten suppository generally provokes immedi- 
ate action of the bowels. Yet glycerin suppositories may 
prove too irritating to the rectum for continued use. 

Indigestion. 

Symptoms. Flatulence, sour, green and curdy stools, 
vomiting an hour or more after nursing or feeding, restless- 
ness, disturbed sleep, colic, failure of the normal gain in 
weight. 

Treatment. Regulate the nursing or feeding. The 
food is almost invariably the source of the trouble. Look 
to the health and habits of the mother. It is sometimes 
useful to dilute the mother's milk by giving the child 
a teaspoonful or two of warm water with the nursing. 
Frequently the first thing needed is to relieve the stomach 
of its contents by lavage. In acute indigestion four to five 
-^-grain doses of calomel may be useful. Pepsin, gr. j, 
in warm water, 5j, with each feeding may be given with 
benefit, for a time, in certain forms of indigestion. 



186 ESSENTIALS OF OBSTETRICS. 

Colic. 

Treatment. Remove the cause, which is to be found 
in faulty digestion, by regulating the feeding. 

For the pain choral is almost a sovereign remedy. The 
dose is gr. j in water, 5j, or in syrup of vanilla and water, 
aa 5ss, repeated once to three times daily, p. r. n. ; warm 
applications to the abdomen and warm rectal injections, oj, 
are useful palliatives. The curative treatment must consist 
mainly of measures addressed to the digestive disorder. 

Simple Diarrhoea. 

Treatment. Look to the feeding and the digestion. 
All feeding may sometimes be suspended for several hours 
to advantage. A mild laxative may be indicated to remove 
irritating material ; then bismuth subnitrate, gr. iij to v, 
may be given after each diarrhoeal movement. Should this 
fail add camphorated tincture of opium, ffiiij to vj, to each 
dose of the bismuth. 

Thrush. 

Symptoms. The mucous membrane of the mouth is 
studded with white patches, due to the presence of a fungus. 
The patches resemble milk-curds in appearance, but are dis- 
tinguished from them by their firm adhesion and by the 
detection of the mycelia and spores of the parasite under 
the microscope. 

Treatment. To destroy the fungus sop the patches 
every two hours with a saturated solution of boric acid or 
with a solution of sodium sulphite, one drachm to the ounce. 
For the stomatitis which persists after destruction of the 
fungus use a half-saturated solution of potassic chlorate, or 
better, as being less toxic, sodic chlorate, as a mouth-wash. 
The child must not be permitted to swallow any of these 



PHYSIOL OGY OF THE P UEBPEBAL ST A TE. 187 

solutions. The accompanying -gastrointestinal disorders are 
to be treated as in other cases. 

Intertrigo. 

Treatment. Keep the parts clean, with care to do no 
mechanical violence to the skin by too much friction. Use 
as an infant powder lycopodium and oxide of zinc, equal 
parts, dusted on the affected surfaces after cleansing, p. r. n. 
Talcum powder is a useful application. 

Cephalhematoma. 

Cephalhematoma is an extravasation of blood, usually be- 
tween the pericranium and the cranial bones • rarely it occurs 
internally. After a few days a hard ridge develops at the 
margin of the tumor owing to periosteal inflammation. 

Its situation is most frequently over one parietal bone ; 
exceptionally it is the site of the caput succedaneum. 

Prognosis. In the internal form the prognosis is grave 
if cerebral symptoms develop. The external variety, as a 
rule, terminates in subsidence of the tumor in about three 
months. 

Treatment. If the swelling grows it may be firmly 
strapped after shaving the head. If pus forms early inci- 
sion is indicated. Otherwise no treatment is considered 
advisable by most authorities. The writer has practised the 
evacuation of the blood within a few days after birth by a 
small incision. The tumor must first be shaved and the 
strictest asepsis be observed. A firm antiseptic compress is 
applied and held in place with a roller bandage. When the 
incision has been delayed for one or two weeks a longer in- 
cision may be required owing to the presence of blood-clots. 
Should the hemorrhage persist after opening the tumor it 
may be controlled by pressure. 



188 ESSENTIALS OF OBSTETRICS. 

Preputial Adhesion. 

In male children the adhesion of the foreskin to the glans, 
which is usually physiological in newborn children, may 
cause irritability of the bladder and other reflex disturbances. 
In such cases the preputial orifice should be very gently 
dilated and the adhesion broken up till the foreskin can be 
fully retracted. Nicking the foreskin with scissors in the 
median line on the dorsum may be required to permit re- 
traction. Drawing back the prepuce, it is liberated from 
the glans by the aid of a smooth, blunt, stiff probe ; a dress- 
ing of vaselin or of bismuth powder together with daily 
retraction will prevent re-adhesion. 

Icterus. 

Icterus occurs in a large proportion of newborn infants. 
It begins from the first to the fifth day after birth, most fre- 
quently on the third or fourth. The pathology is in dispute. 
The icterus is probably due to destruction of red blood- 
corpuscles and consequent excessive formation of bile pig- 
ment in the liver. It is observed most frequently in pre- 
mature and feeble infants and after difficult labor. 

The conjunctivae and the urine may or may not be stained. 
In well-marked cases the stools are clay-colored. In the 
mild form the icterus disappears within six or eight days ; 
in the more severe it may last for two weeks or more. 

Treatment. As a rule none is required. In persistent 
cases attention to the digestion, keeping the bowels open 
by enemata, or, if need be, by the use of a mild laxative, 
as sodium phosphate, constitute the treatment. 

In persistent icterus with increasing discoloration, and 
especially with the presence of sepsis and high temperature, 
treatment is generally futile. 



PHYSIOLOGY OF THE PUERPERAL STATE. 189 

Ophthalmia. 

Cause. In the vast majority of cases the cause is infec- 
tion from the genital tract of the mother by the gonococcus 
of Neisser. It generally begins on or before the third day. 

Prognosis. The prognosis for the sight is grave in the 
absence of timely treatment. Twenty-five per cent, of all 
cases of total blindness in asylums are due to this cause. 
Almost without exception under skilfully conducted manage- 
ment the suppuration is promptly controlled and the sight 
is not impaired permanently. 

Treatment. Prophylactic. Disinfect the maternal pas- 
sages before and during labor in case of gonorrhoeal secre- 
tion. Cleanse and dry the child's eyes immediately after the 
head is born. Instil one or two drops of a 2 per cent, solu- 
tion of nitrate of silver into each conjunctival sac shortly 
after birth. (Crede.) The prophylactic use of Crede' s solu- 
tion is the rule in hospital practice. The eyes of every 
child are treated with the nitrate of silver solution within a 
few minutes after birth. A similar precaution may well be 
observed in private practice. It should never be omitted 
when the mother is known to be the subject of leucorrhoeal 
discharges. When properly employed the immunity is prac- 
tically absolute. Should the use of the silver solution be 
followed by much serous oozing the latter may be promptly 
relieved by a single application to the conjunctivae of a one- 
grain solution of atropine, one drop in each eye. 

Curative. At the onset of the inflammation cold ice- 
water compresses are useful in the absence of corneal com- 
plications. 

Cleansing. Removal of the pus every hour or two by 
irrigating or bathing with a warm saturated boric-acid solu- 
tion is essential. 

9* 



190 ESSENTIALS OF OBSTETRICS. 

Silver- nitrate. After free discharge is established brush 
the conjunctival surfaces after cleansing once or twice daily 
with a 2 to 4 per cent, aqueous solution of nitrate of silver. 
This is continued till the discharge loses its purulent char- 
acter. Frequent cleansing with the boric-acid solution must 
still be practised till all discharge ceases. Anointing the 
edges of the lids with vaselin favors drainage by preventing 
the lids from becoming glued together. The nurse should 
be drilled in the method of manipulating. 

As a rule the advice of an oculist should be had. 1 

Umbilical Infection. 

The cause is uncleanliness in the care of the umbilical 
wound. The infecting organism is most frequently the 
streptococcus. The septic process may result in a mere 
local ulcer or in umbilical phlebitis and septicaemia. In 
the latter event the termination is fatal usually by convul- 
sions. Pus may be present in the umbilical vessels from 
infection through the navel even when the wound has 
healed promptly. Cellulitis of the abdominal walls and 
peritonitis are frequently observed. Septic processes in 
remote organs are common comolications. 

Treatment. In local sepsis frequent antiseptic cleans- 
ing of the wound surface and dressing with aristol, bismuth 
powder or iodoform and bismuth suffice. The peroxide 
of hydrogen is a good antiseptic for disinfecting the wound 
surface. It is non-poisonous and practically non-irritant. 
Inunctions of quinine and the use of stimulants by the 



1 In New York State a midwife or nurse who may be cognizant of any inflam- 
matory affection in the eyes of an infant under her care is required by law to 
report the fact in writing, within six hours, to the Health Officer, or to some 
legally qualified practitioner of medicine in the city, town or district in which 
the parents reside. 



PHYSIOLOGY OF THE PUERPERAL STATE. 191 

stomach help to increase the resisting power. In systemic 
infection treatment is futile. 

Tetanus Neonatorum. 

The disease begins toward the end of the first week. The 
cause is infection, generally of the navel, with the tetanus 
bacillus. 

The symptoms are those of surgical tetanus. The ter- 
mination is almost invariably fatal within two or three 
days. 

Treatment. As far as possible all sources of peripheral 
irritation should be removed. Feeding is maintained by the 
stomach-tube passed through the nostrils, using pre-digested 
milk, or, this failing, by rectal injections. The drug treat- 
ment consists in the use of potassium bromide, gr. iv every 
two to four hours, or of chloral, grain j every hour, p. r. n. 
These remedies must be given by a stomach-tube or by a 
rectal tube. Sulphonal, gr. iij every two hours, by the 
rectum, has been used with success. The value of the serum 
treatment is still sub judice. 

Umbilical Hemorrhage. 

Umbilical hemorrhage may proceed from faulty ligation 
of the cord, syphilis, sepsis, acute fatty degeneration with 
hemoglobinuria or hemophilia. The hemorrhage usually 
begins within a week or a little more after birth. Eighty 
per cent, of the children die. 

Treatment. In simple cases re-ligate the cord and 
apply a compress, or lift the umbilicus, transfix with a 
harelip-pin and apply a figure-of-eight ligature. In cases 
dependent on a dyscrasia treatment is generally futile. 



192 ESSENTIALS OF OBSTETRICS. 

Mastitis. 

Swelling of the breasts is frequently observed in newborn 
children during the first week. As a rule it calls for no 
treatment. If pus form, which is very rarely the case, it 
should be evacuated. 

A Bloody Genital Discharge. 

A bloody genital discharge is sometimes observed in 
female children the first few days after birth ; no treatment 
is required. 



CHAPTER V. 
PATHOLOGY OF PREGNANCY. 

DISEASES OF THE DECIDILE. 

Acute Endometritis. Acute endometritis may be 
present in the course of acute febrile disease. It is often 
attended with hemorrhage and frequently results in abortion. 

Chronic Diffuse Endometritis. The causation is not 
fully understood. The anatomical changes in the decidua 
are mainly hypertrophic. It occasionally gives rise to 
abortion. 

Catarrhal Endometritis. Catarrhal endometritis is 
attended with a discharge of watery mucus from the uterus — 
hydrorrhcea gravidarum ; it is most common in the later 
months of pregnancy. Sometimes the fluid collects between 
the chorion and the decidua and is discharged in gushes. 
Rarely the uterus becomes excessively distended by the 
accumulated fluid. The inflammation affects most fre- 
quently the vera ; it may also involve the reflexa. It is 
attended with hypertrophy of the connective tissue and of 
the glandular elements. Exceptionally it terminates in 
abortion or premature labor. 

In this condition the hyperplasia of the uterine mucosa, 
which is normal to the early months of pregnancy, is exag- 
gerated and is continued to the later months of gestation. 
It affects all the elements of the decidua and results in a 
greatly increased thickness of this structure. Hemorrhage 



194 ESSENTIALS OF OBSTETRICS. 

frequently occurs into the decidua. Cysts have been 
observed. The cause is a persisting endometritis which 
may be of the septic, syphilitic or gonorrhoeal type. 

When the process is rapidly developed it is attended 
with hemorrhages into the decidua or with partial separa- 
tion of that structure ; abortion or premature labor is the 
rule. 

Debility and ansemia frequently result from hydrorrhoea. 
The discharges are to be distinguished from liquor amnii, 
from urine and from leuchorrhceal secretions. 

Treatment. The treatment is to be addressed mainly 
to the resulting debility and anemia. The arsenate of iron 
or other hematinic and general tonics are indicated. 

Cystic Endometritis is distinguished by the formation 
of retention cysts due to obstruction of the gland-ducts by 
proliferation of interglandular connective tissue. Here, too, 
there is hydrorrhoea. 

Polypoid Endometritis is rarely met with. It is charac- 
terized by polypoid growths upon the ovular surface of the 
decidua, in addition to the lesions of simple diffuse endo- 
metritis. The pathological changes are generally limited 
to the decidua vera. Rarely, however, they involve the 
serotina. The placental villi may undergo hypertrophy or 
myxomatous degeneration. Death of the foetus and abor- 
tion usually result. 

ANOMALIES OF THE AMNION AND THE LIQUOR 
AMNII. 

Oligohydramnios. The quantity of amnial liquor at 
term is normally about two pints. Oligohydramnios is a de- 
ficiency of liquor amnii. Extreme scantiness of the amnial 
liquor may be attended with adhesions between the amnion 



PATHOLOGY OF PREGNANCY. 195 

and the foetus and with the formation of amniotic bands. 
Intra-uterine amputation of foetal extremities and develop- 
mental faults sometimes result from these amniotic bands. 
Harelip, cleft palate, navel-cord hernia, and spina bifida 
are frequently produced by this agency. Oligohydram- 
nios is one of the causes of club-foot. 

Hydramnios or Polyhydramnios may be defined as an 
excess of liquor amnii over 4 pints. In extreme cases the 
quantity may reach 30 to 50 pints. 

Polyhydramnios occurs much more frequently in multi- 
parae than in primipane. It is usually present to some 
degree in twin pregnancies. Excess of liquor amnii may 
exist in one foetal sac and deficiency in the other. Great 
excess of the amnial liquor is often attended with malforma- 
tion of the foetus. It begins most frequently in the latter 
half of pregnancy and is observed once in about three 
hundred pregnancies. 

Causes. Among the causes assigned are maternal 
anasarca, abnormal persistence of the vasa propria (a capil- 
lary network of the subplacental chorion immediately 
underlying the amnion, and which is normally present in 
the early months of gestation), excessive secretion of urine 
by the foetus, exudation of the foetal skin, amniotitis, decid- 
ual disease, deficient resorption of liquor amnii. Foetal 
syphilis is a possible cause. 

Diagnosis. The more important physical signs are ex- 
cessive size and permanent tension of the uterine tumor, 
suprapubic oedema, preternatural mobility of the foetus. 
In extreme amniotic distention the cervix is obliterated. 
Hydramnios is distinguished from ascites, ovarian cyst and 
twins, by palpation and auscultation of the tumor and by 
the history. The differential diagnosis will be found dis- 
cussed under the topics referred to. 



196 ESSENTIALS OF OBSTETRICS. 

Pkognosis. The prognosis is unfavorable to the child, 
owing to premature birth, dropsical affections, malforma- 
tions and malpresentation, which are common in hydram- 
nios. The foetal mortality is 25 per cent. For the mother 
the prognosis is generally good. 

Treatment. In case of alarming symptoms from over- 
distention puncture of the membranes, with care to guard 
against syncope from too rapid escape of the liquor amnii, 
is permissible. On the birth of the child precautions may 
be needed against post-partum hemorrhage. Special care 
must be taken to promote retraction of the uterus after 
delivery. 

DISEASE OF THE CHORION. 

Cystic Degeneration of the Chorion, Vesicular Mole, 
Hydatidiform Mole, may be defined as " an hypertrophy 
and myxomatous degeneration of the chorial villi, attended 
with the formation of cysts." The cysts vary in size from 
that of a millet-seed to a grape — they may reach the size of 
a hen's egg. Each cyst springs from another and not from 
a common stalk. They may be many thousand in number 
and the total mass as large as the mother's head. Very 
rarely the villi perforate the uterine wall, leading to rupture 
of the uterus and peritonitis. The cyst content is a clear 
watery fluid containing albumin and mucin. The degenera- 
tion begins most frequently in the very first weeks of gesta- 
tion. In twin pregnancies one or both ova may be affected. 

It is met with most frequently in women who have borne 
children, sometimes in more than one pregnancy in the 
same individual. It occurs once in something more than 
two thousand pregnancies. 

Etiology. Of the etiology little is known. The cause 
apparently resides in the ovum. Endometritis, syphilis 



PATHOLOGY OF PREGNANCY. 197 

and absence or deficiency of allantoic vessels, commonly 
assigned as causes, probably have no part in the etiology. 

Diagnostic Signs. Signs of pregnancy ; 

Abdominal enlargement out of proportion to the stage of 
gestation ; the uterus is too large the first three months, later 
it is sometimes too small ; 

Absence of ballottement, of the foetal heart, of foetal 
parts and of foetal movements ; 

Uterus usually doughy ; 

Sero-sanguineous discharge ; 

Expulsion of cysts, rarely noted ; 

Detection of the cysts by direct exploration of the uterine 
cavity. The disease is rarely recognized till after the third 
month. 

Prognosis. The maternal mortality is 10 to 15 per 
cent. Immediate causes of death are hemorrhage, sepsis 
and rupture of the uterus. Except in rare cases of partial 
degeneration the embryo invariably dies and disappears by 
absorption. The degenerated ovum may be retained for 
many months, usually it is expelled before the sixth. 

Treatment. If no evidence can be found that the foetus 
is living the uterus should be emptied. The cervix is to be 
dilated and the evacuation of the uterine cavity begun with 
hand or dressing-forceps. This must be done cautiously, 
since the uterine wall is often extremely thin. Curettement 
is practised after considerable retraction has taken place. 
The uterus is washed out with a hot, mild antiseptic douche 
and its cavity swabbed with tincture of iodine. Ergot is 
given, if required, to make the uterus contract. 

ANOMALIES OF THE PLACENTA. 

Placenta Membranacea. A placenta membranacea is 
a broad, thin placenta with persistence of the villi over the 



198 ESSENTIALS OF OBSTETRICS. 

entire surface of the chorion. Abnormal adhesion is common 
with this anomaly. 

Placenta Praevia. The placenta is prsevia when its 
attachment encroaches upon that portion of the uterus 
which is subject to dilatation during the first stage of 
labor. 

Placenta Succenturiata. Subsidiary 'placenta. This 
term is applied to a wholly or partially independent pla- 
cental cotyledon. The anomaly is usually single, sometimes 
multiple. 

Cysts of the placenta are of frequent occurrence. The 
cysts are small and are seated beneath the amnion. They 
are probably developed from the chorial villi. 

Syphilis. The syphilitic placenta is larger and paler 
than normal, and yellowish in patches. In syphilis of 
paternal origin the foetal structures of the placenta are 
affected ; when the disease is of maternal origin the decidua 
is involved; in the tertiary stage gummata are present. 
Syphilis of the placenta is always dangerous, and may be 
fatal, to the foetus. 

(Edema may be present in hydramnios, in occlusion of 
umbilical veins or in maternal anasarca. 

Apoplexy. Extravasations of blood into the placenta 
may occur at one or several points. Hemorrhages in the 
early months of pregnancy occur near the foetal surface, in 
the later months near the maternal surface of the placenta. 
The causes are placentitis, general infectious diseases, ne- 
phritis, pelvic congestion, traumatism. Extensive effusions 
of blood result in the death of the embryo or foetus and con- 
sequent abortion or premature labor. Small extravasations 
are generally tolerated with no apparent ill-result. Small 
blood-collections may be found partially organized, or may 
become fatty or calcareous. 



PA THOL OGY OF PBEGNANG Y. 199 

Myxomatous Degeneration usually involves only a part 

of the placenta. (See Vesicular Mole, page 196.) 

Fatty Degeneration may result from endometritis, pla- 
cental hemorrhage or chronic inflammation of the placenta. 
Death of the foetus may ensue. 

Placentitis may affect the whole, rarely a portion only, 
of the placenta. Placental inflammation may result from 
an endometritis existing at the time of conception, or from 
syphilis or acute sepsis. The normal placental structure 
is replaced by fibroid tissue. There are hypertrophy and 
sclerosis of the decidua. Abnormal adhesions of the pla- 
centa are attributed to this cause. 

Calcareous Degeneration is common and is unim- 
portant. 

White Infarcts are very commonly observed in the pla- 
centa. They are dense whitish or yellowish masses varying 
in size from one to two or three centimetres in diameter. 
They are of no pathological importance when small and few 
in number. When numerous and extensive they may cause 
the death of the foetus. They have their origin in local 
degeneration of the decidua. 

ANOMALIES OF THE UMBILICAL CORD. 

Length. Excessive length of cord may predispose to 
prolapse, to torsion, to knots, or to coils about the foetus 
and to obstruction in the funic vessels. A short cord may 
lead to premature separation of the placenta during labor. 

Excessive Torsion of the umbilical vessels may cause 
partial occlusion. It is sometimes accompanied with serous 
effusion into the peritoneal cavity of the foetus and with 
cedematous swelling of the cord. In most cases torsion of 
the cord itself is developed only after the death of the foetus. 



200 ESSENTIALS OF OBSTETRICS. 

Knots rarely occur. They result from the passage of the 
foetus through a loop of the cord. They are seldom tight 
enough to endanger the foetus. 

Hernia. Hernial protrusion of omentum or intestinal 
loops may take place into the cord. It results from imper- 
fect closure of the abdominal walls at the umbilicus, and is 
usually accompanied with other errors of foetal develop- 
ment. 

Cysts are frequently observed in the sheath of the cord. 
They are due to liquefaction of mucoid tissue or of blood 
extravasations. 

Coils about the foetus, especially the neck, are of fre- 
quent occurrence. Sometimes an arm or a leg is thus 
encircled. Rarely is the circulation impeded either in the 
funis or the girdled member. Extensive coilings may give 
rise to the dangers of short cord. 

Coiling of the cord about the neck of the child may 
sometimes be recognized during pregnancy by depressing 
the abdominal walls of the mother opposite the child's neck; 
the foetal pulse-rate is retarded when the cord is pressed 
upon. 

The insertion may be eccentric, marginal or velamen- 
tous. In the latter anomaly the vessels pass for a greater 
or less distance between the membranes to the edge of the 
placenta. As the vessels are more or less separated and 
unprotected they are liable to be torn during labor. Such 
an accident almost surely results in the death of the child 
unless it is promptly born. 

When the insertion of the cord is marginal the placenta 
is sometimes termed a battledore placenta. 



PATHOLOGY OF PREGNANCY. 201 

PATHOLOGY OF THE FOETUS. 

ANOMALIES OF DEVELOPMENT. 

The principal anomalies of foetal development are briefly 
the following -} 

(a.) Hemiteria. Literally, half monstrosity. Under 
this head are included dwarfs and giants, microcephalia, 
sternal fissure, spina bifida, club-foot, supernumerary digits, 
double uterus, double vagina, supernumerary ribs, etc. 

(b.) Heterotaxia. Under this head are included trans- 
position of viscera, hernial protrusion, imperforate rectum, 
vagina, oesophagus, etc., persistent foramen ovale, persistent 
ductus venosus, persistent ductus arteriosus, etc, webbed 
fingers or toes, harelip, cleft palate, epispadias, hypospadias, 
hermaphrodism. 

(c.) Teratism. 1. Ectromelic monster. Having one 
or more aborted extremities. 

2. Symelie monster. Having its lower limbs partly or 
wholly united. 

3. Qelosomatic monster. Having partial or complete even- 
tration. 

4. Exencephalic monster. In this anomaly the brain is 
malformed and protruding from the cranial cavity. 

5. Pseudencephalic monster. Here the cranial vault 
and the larger part of the brain are absent. 

6. Anencephalie monster. The cranial vault and the 
entire brain are wanting. 

7. Cyclo cephalic monster. A monster in which the nose 
is wanting and the eyes are partially fused into one. 

8. Otocephalic monster. The ears meet or are fused in 
the median line. 

1 In part after Norris. 



202 ESSENTIALS OF OBSTETRICS. 

9. Omphalositic monster. This monster is one of twins 
which has a parasitic existence in utero. Its nourishment 
is derived from the companion foetus, and it is incapable of 
living independently after the cord is divided. The anomaly 
owes its origin to the fact that the circulation of one foetus 
has overpowered and reversed that of its companion. 

10. Double monster. Two foetuses united. 
Varieties : (a.) Sternopagus, joined at the sternum ; 

(b.) Isehiopagus, joined at the pelvis ; (c.) Cephalopagus, 
joined at the head; id.) Xiphopagus, joined at the xiphoid 
cartilage. 

Syncephalic. The heads partly fused, the bodies sepa- 
rate. 

Monocephalic. The heads completely fused, the bodies 
separate. 

Synsomatic. The bodies are partially fused, the heads 
separate. 

Monosomatic. The bodies are wholly fused, heads sepa- 
rate. 

Double Parasitic Monster. One foetus is attached as a 
parasite to the other, or inserted or included in it. 

DISEASES OF THE FCETUS. 

The foetus is subject to many of the infectious and other 
general diseases of post-natal existence. Well-known ex- 
amples are variola, typhoid fever, pneumonia, syphilis, scar- 
latina, measles, rachitis, valvular disease of the heart, serous 
effusions, etc. 

FCETAL DEATH. 

Diagnosis. Signs of foetal death are : 
Recession of the signs of pregnancy ; 
Uterus doughy ; 



PA THOL G Y OF PBEGNANO Y. 203 

Peptonuria : 

Acetonuria : 

Cervical temperature not above the vaginal : 

Absence of foetal heart-tones; 

Absence of active foetal movements — examine by ab- 
dominal palpation and by the bimanual ; 

Absence of the choc foetal ; 

Looseness and crepitation of cranial bones. 
The mother frequently experiences periods of illness and 
a sense of weight in the abdomen. 

In most cases of suspected death of the foetus repeated 
examinations will be required to decide the question. The 
diagnosis of death of the ovum is especially difficult in the 
early months of development before the period when in the 
living foetus the heart can be heard or active movements 
felt. 

The recognized causes of intra-uterine death, such as 
mechanical violence, maternal toxaemia or profound anaemia, 
syphilis, etc.. should be sought for. 

Habitual death of the foetus, in a great majority of cases, 
is the result of syphilis in one or both parents. The most 
important signs of foetal syphilis to be found by post-mortem 
dissection are osteochondritis, between the diaphysis and 
epiphysis of the long bones, especially at the lower end 
of the femur, enlargement of the liver, often to one-twelfth 
or even one-eighth the body-weight, enlargement of the 
spleen. 

Changes in the Foetus after Death in Utero. 

The dead fcetus carried in utero undergoes either absorp- 
tion, mummification, maceration or putrefaction. 

Absorption. This occurs usually when the fcetus dies in 
the first two months of gestation. The embyro in course 



204 ESSENTIALS OF OBSTETRICS. 

of a few days after its death becomes liquefied and ab- 
sorbed. 

Fleshy Mole. Sometimes when the ovum is carried in 
utero for a long period after the death and absorption of the 
embryo the uterine contents are reduced to a dense mass 
of placental structure and organized blood-clot known as a 
fleshy mole. This may be retained for many weeks. 

Mummification takes place only when the foetus has 
died in the middle or later months of development. The 
soft structures become dried and shrunken and the skin 
assumes a yellowish-gray color. The placenta undergoes 
somewhat similar changes. A foetus papyraceus is a mum- 
mified twin foetus which after death in utero has become 
flattened by the pressure of its living companion. The 
head in such cases is frequently pressed into the shape of a 
meniscus lens. • 

Maceration. In maceration of the foetus the tissues 
become softened and sometimes swollen and the abdomen 
is distended. The epidermis is exfoliated and the serous 
cavities contain blood and serum. The odor is sickening, 
but not putrefactive. 

Putrefaction takes place only when the foetus is carried 
for a time in utero after the membranes have ruptured. 
The connective tissues become emphysematous, the abdomen 
distended and the body emits a putrefactive odor. The 
uterus sometimes is tympanitic and the mother suffers more 
or less from septic absorption. 

Treatment in F(etal Death. The uterus should be 
emptied immediately the diagnosis of foetal death can be 
positively established. The presence of a dead foetus in 
utero is always injurious to the health and may become 
dangerous to the life of the mother. 

In the first three or four months of pregnancy the method 



PATHOLOGY OF PREGNANCY. 205 

to be pursued is the same as for the induction of abortion. 
In the later months labor is induced as in other cases of 
advanced pregnancy. 

ABORTION. 

Frequency. It is estimated that not far from 20 per 
cent, of pregnancies end in abortion. This estimate is 
doubtless too small if abortions from all causes are included. 
Owing to the influence of the menstrual molimen sponta- 
neous abortions occur most frequently at the end of the 
menstrual month. In a large proportion of cases they take 
place at the second month, and are comparatively infrequent 
after the third. 

Causes. In considering the etiology of abortion it must 
be borne in mind that the security of attachment between 
the ovum and the uterus differs greatly in different cases. 
Influences quite sufficient to bring about the expulsion of the 
ovum in one pregnancy may have no such effect in another. 

The provoking causes of abortion may be grouped under 
two heads: 1. Those which act by first causing the death 
of the foetus. 2. Those which act independently of the death 
of the foetus. In the great majority of cases abortion results 
from the death of the foetus. 

1. Death of the foetus may occur from: Malformation, 
disease, mechanical violence, maternal toxaemia or excessive 
anaemia, pathological conditions of the chorion, the amnion, 
the cord, the decidua. 

2. Causes acting independently of the death of the foetus 
are atrophy or hypertrophy of the endometrium, placenta 
praevia, oxytocics, reflex irritation of the uterus, e. g., from 
mammary or from rectal stimuli, epileptiform convulsions 
from uraemic or other causes, carbon dioxide poisoning, 

10 



206 ESSENTIALS OF OBSTETRICS. 

placental apoplexies, pelvic adhesions, uterine myomata, 
cancer of the uterus, misplacement of the uterus, over-dis- 
tention from hydramnios or from multiple pregnancy, direct 
interference, falls or blows, hyperemia of the pelvic organs 
from circulatory obstruction in the lungs or liver, from 
valvular heart disease, from violent muscular exertion, or 
from sexual excesses, etc., resulting in hemorrhage into the 
placenta. 

Diagnosis. Symptoms. The symptoms of beginning 
abortion are : Hemorrhage, pelvic tenesmus, rhythmical 
uterine pains. 

Physical Signs. The physical signs are effacement of 
the os internum, dilatation of the cervix and partial pro- 
trusion of the ovum from the uterine cavity. 

The physical signs establish the diagnosis of inevitable 
abortion. They imply a degree of separation of the ovum 
from the lower uterine segment too great to permit the 
farther continuance of the gestation. Severe rhythmical 
pains with hemorrhage almost surely forebode the expulsion 
of the ovum. Not only should a thorough physical ex- 
amination of the pelvic organs be made in every case of 
suspected abortion, but blood-clots and other material cast 
off from the genital passages should be inspected. Other- 
wise the ovum when expelled enveloped in a mass of coagu- 
lated blood may escape observation. Clots are best examined 
by breaking them up under water. 

Abortion in the first weeks of gestation is not always 
easily distinguished from dysmenorrhoea or simple uterine 
hemorrhage. Here the diagnosis will depend mainly on 
the evidence of pregnancy as shown by the shape, size and 
consistence of the uterus, and on the presence of foetal struc- 
tures in the genital discharges. Free hemorrhage with 
expulsion of large blood- clots is significant of abortion. 



PATHOLOGY OF PREGNANCY. 207 

Prognosis. There is no mortality in properly conducted 
abortions, yet many deaths occur from mismanagement. 
The principal sources of danger are hemorrhage and septi- 
caemia. Hemorrhage contributes to the fatal issue, though 
it is rarely the immediate cause of death. The danger of 
sepsis is especially imminent in incomplete abortion. The 
presence of necrotic material in the uterus is a serious 
menace to life. It is a potent cause of pelvic inflammation 
in cases which escape a fatal termination. 

Treatment, (a.) Prophylaxis in habitual abortion. 
The preventive treatment of abortion is addressed chiefly to 
the cause. 

Syphilis in one or both parents, retroversion of the 
uterus and endometritis are the most frequent causes of 
habitual abortion. Syphilis is treated as in other cases. It 
is not always possible to save the ovum by treatment begun 
after conception. 

Retroversion is corrected and its recurrence is prevented 
by the use of a suitable pessary till after the third month. 

Endometritis is best treated by curettage in the interval 
between pregnancies. It is important to guard against 
overexertion, mechanical violence and the causes of pelvic 
congestion, especially at the menstrual dates. Rest in bed 
during the menstrual epochs and abstention from sexual 
intercourse should be enjoined till the critical period has 
passed. 

(b.) Arrest of threatened abortion. Enforce absolute rest 
in the recumbent position. The patient should not be per- 
mitted to rise for any purpose till all symptoms of abortion 
have subsided. Uterine rest is maintained by the use of 
opium, gr. ij, or its equivalent, p. r. n. A four-grain pill 
of extract of viburnum prunifolium is useful as an adjunct, 
even as a substitute for opium. Misplacements of the 



208 ESSENTIALS OF OBSTETRICS. 

uterus must be corrected. Exclude vesicular degeneration 
of the chorion and death of the embryo or foetus, in either 
of which conditions the uterus should be evacuated. 

(<?.) Management of actual abortion. The general objects 
of treatment are the prevention of : 1. Hemorrhage; 2. Sep- 
ticaemia. 

Measures for controlling hemorrhage are : 1. Rest ; 2. Firm 
cervical and vaginal tamponade ; 3. Evacuation of the uterus. 

Means for averting or controlling sepsis are : 1. The 
avoidance of preventable lacerations and abrasions ; 2. 
Asepsis ; 3. Timely evacuation of the uterus. 

1. Expectant Plan. Indications : Ovum but little de- 
tached, hemorrhage slight, sepsis absent. 

Method. Usually no interference is practised except 
such as is needed for cleanliness. An aseptic vaginal tam- 
pon may be used if required as a safeguard against hemor- 
rhage. This plan failing, after twenty-four hours empty 
the uterus with curette and forceps — sooner for cause. 

Method of tamponade. Place the patient in the Sims 
position and expose the cervix with a Sims speculum. 
The material for the tampon may be aseptic cotton-wool, 
used wet enough to pack firmly, and in pledgets the size of 
a chicken's egg. Place a row of pledgets in the fornix, 
around the cervix, and build up from this until the vagina 
is full. Press the packing away from the urethra and base 
of the bladder to prevent vesical irritation. Hold it in place 
with a T-bandage. Sterilized gauze in strips two and one- 
half inches wide and five yards long is a better material for 
the tampon than the cotton-wool. The simple aseptic pack- 
ing must be renewed every twelve hours. A tampon im- 
pregnated with oxide of zinc may stand twenty-four hours. 
Mercurials should not be used in the tampon. The vagina 
should be irrigated at each renewal of the dressing. 



PATHOLOGY OF PREGNANCY. 209 

2. Radical Plan. Indications : Cervix dilated, the ovum 
detached or presenting or partially expelled, hemorrhage ex- 
cessive, sepsis present or imminent. 

Manual method. The abdomen, thighs, vulva and vagina 
are thoroughly cleansed with soap, hot water and a soft 
brush, and the vagina again gently scrubbed with a soft 
cheese-cloth sponge held in the grasp of a dressing-forceps, 
and finally irrigated with the antiseptic solution for five min- 
utes. The cervical canal is freed from mucus and disinfected. 

An anaesthetic will be required. The uterus is crowded 
down and fixed with one hand over the abdomen, and the 
cavity is evacuated with one or two fingers of the other hand, 
aseptically. The manual method is awkward, difficult and 
painful, except the ovum is nearly or quite detached and the 
cervix well open ; even then it is inferior to the instrumental. 

Instrumental method. Anaesthesia is necessary as a 
rule. The patient may be placed in the Sims or in the 
dorsal position, and the cervix exposed by means of a Sims 
speculum or other suitable retractor. The vagina and the 
cervix are cleansed as already detailed. The anterior lip 
of the cervix is caught and held gently forward toward the 
pubic bones with a volsella The uterine cavity, if septic, is 
douched with the antiseptic solution, otherwise with the salt 
solution (j 7 q- per cent.), or with plain sterilized water. The 
ovum is detached with the curette and removed with a pair of 
long, straight, uterine dressing-forceps having a joint about 
two and a half inches from the distal end. Every part of the 
cavity is curetted thoroughly with a sharp curette and again 
douched. Care will be required to remove all the decidua from 
the cornua. A special small curette will be found useful for 
this purpose. The uterus after complete evacuation may 
be swabbed with tincture of iodine if hemorrhage is not con- 
trolled by the curette. As a rule only weak antiseptic 



210 ESSENTIALS OF OBSTETRICS. 

solutions or plain sterilized water should be used in the 
uterus in the absence of septic material. Strong anti- 
septics leave a superficial necrotic layer which furnishes a 
favorable nidus for the growth of septic organisms. A 
relaxed uterus after abortion calls for ergot. If the secun- 
dines are necrotic the uterine cavity may be lightly packed 
with a strip of iodoform gauze an inch in width. The pack- 
ing should be removed after twenty-four or thirty-six hours. 

The presence of a peri- or parametritis does not forbid 
interference. It makes it rather the more imperative. 
Sepsis in the uterine cavity tends to perpetuate the peri- 
uterine inflammation, maintaining the supply of septic ma- 
terial. 

Incomplete Abortion. Continuous or irregular hemor- 
rhage, sepsis or failure of involution after abortion is prob- 
able evidence that portions of the ovum have been retained. 
In such cases the uterine cavity should be disinfected, ex- 
plored and, if necessary, curetted and lightly packed with 
iodoform gauze. 

After-treatment of Abortion. The patient remains 
in bed for a week or more. The external genitals must be 
kept scrupulously clean. If the uterine cavity has been 
completely and aseptically evacuated after abortion subse- 
quent interference within the passages will not be required. 
The temperature and the character of the genital discharge 
are to be watched for several days. Before the case is finally 
dismissed the physician should assure himself of the condi- 
tion of the pelvic organs by careful bimanual examination. 

PREMATURE LABOR. 

The causes of premature labor are essentially those of 
abortion. Its course and management do not differ in any 
important particular from those of labor at term. 



PATHOLOGY OF PREGNANCY. 



211 



ECTOPIC GESTATION. 

Definition. Pregnancy outside the uterine cavity. 

Varieties, (a.) Tubal pregnancy. In tubal pregnancy 
the impregnated ovum lodges and begins development in 
the Fallopian tube. Practically all extra-uterine pregnancies 
are primarily tubal. 

Fig. 53. 




Ectopic pregnancy ; rupture of fruit-sac into peritoneum. (After Schaeffer. 



(5.) Abdominal pregnancy. Sooner or later, if the devel- 
opment of the ovum is not interrupted, the tube ruptures, 
either into the peritoneum or the broad ligament, because 
incapable of accommodating itself to the growth of the ovum. 
When after rupture of the tube and the partial expulsion of 
its contents the ovum survives and grows in the abdominal 
cavity, either within or without the peritoneum, the preg- 
nancy is said to be abdominal. Primary abdominal preg- 
nancy probably does not occur. 

(c.) Ovarian pregnacy. The ovum is impregnated in the 



212 ESSENTIALS OF OBSTETRICS. 

Graafian follicle and developed in the ovary. Ovarian 
pregnancy, however, is so extremely rare that it will be 
dismissed with mere mention. 

Frequency. The frequency of extra-uterine pregnancy 
is variously estimated at from 1 in 313 to 1 in 1200. 

Etiology. The etiology of ectopic pregnancy is still 
obscure. Among the causes which have been assigned are 
partial obstruction of the tube, sacculation of the tube and 
crippled peristalsis or denudation of ciliated epithelium 
from old catarrhal inflammation with consequent loss of 
propelling power. Yet according to Bland Sutton preg- 
nancy is more likely to occur in a healthy tube than in a 
diseased one. 

Clinical Course. Two classes of cases may be dis- 
tinguished according to the location of the fruit-sac : A. 
Pregnancy in the free portion of the tube ; B. Pregnancy 
in the intramural portion, or interstitial pregnancy. 

A. Pregnancy in the free portion of the tube may have 
either of the following terminations : 

1. The ovum may die without rupture or with partial 
rupture of the tube. In this event 

(a.) The ovum may be expelled through the fimbriated 
extremity of the tube into the peritoneal cavity — tubal 
abortion. 

(b.) It may form a mole or a hematosalpinx. 

(c.) It may suppurate, forming a pyosalpinx. 

(d.) In early gestation it may be absorbed ; in more ad- 
vanced pregnancy it may become mummified or be converted 
into adipocere or a lithopsedion. 

2. The tube may rupture into the peritoneum (usually 
before the eighth or twelfth week) with either of the follow- 
ing results : 

(a.) Very rarely the gestation continues as an abdominal 



PATHOLOGY OF PREGNANCY. 21 3 

pregnancy. In these cases the placenta retains its tubal 
attachment, the foetus with its membranous envelope being 
expelled into the peritoneum. 

(6.) Hemorrhage occurs into the peritoneum, the mother 
dying from hemorrhage or peritonitis. 

(c.) The hemorrhage may be spontaneously arrested. 
The ovum may then be absorbed, may suppurate, or may 
remain with little change. 

3. The tube may rupture into the broad ligament. Intra- 
ligamentous rupture may terminate as follows : 

(a.) The placenta not being wholly detached, the ovum 
may continue to grow — intraligamentous pregnancy. This 
form of ectopic gestation may go to term. This is one 
form of abdominal pregnancy. Spurious labor occurs at 
term and the child dies. 

(b.) Death of the ovum and the formation of a hematoma 
may result. 

(c.) The ovum may die and suppurate. A suppurating 
ovum may be discharged piecemeal through the abdominal 
wall, the vagina, the bladder, the rectum ; may result in septi- 
caemia and death. 

(d.) The ovum may die, and, if the development has ad- 
vanced to the later months, be carried indefinitely, with little 
or no alteration of structure, or be converted into a litho- 
psedion or a mass of adipocere. 

4. Pregnancy in the outer end of the tube may become 
a tubo-ovarian or a tubo-abdominal pregnancy. 

B. Pregnancy in the intramural portion of the tube, tubo- 
uterine pregnancy, interstitial pregnancy. 

1. May terminate by the death of the ovum. 

2. May reach term. 

3. May terminate by expulsion of the ovum into the 
uterus. 

10* 



214 ESSENTIALS OF OBSTETRICS. 

4. May rupture into the peritoneal cavity, with death of 
the mother by hemorrhage. Rupture generally occurs 
before the sixth month. 

5. May rupture into the broad ligament. 
Diagnostic Signs in the Early Months. 1. History: 

Antecedent sterility, signs of pregnancy, pain, hemorrhage, 
expulsion of a decidual cast from the uterus. 

2. Uterus : Displaced, according to the size and situa- 
tion of the fruit-sac ; enlarged with rare exceptions, empty, 
cervix open. 

3. Tumor : Beside or behind or in front of the uterus, 
fluid, tense, tender, pulsating, rapidly growing. 

Frequently a long period of sterility has immediately 
preceded the pregnancy. The pain usually occurs in parox- 
ysms, which are abrupt and violent, generally. It is cramp- 
like in character and is referred to the seat of the fruit-sac. 
The final and more acute paroxysms are usually attended 
with collapse and with the signs of internal hemorrhage. 
Exceptionally the symptoms are not well marked. 

The genital hemorrhage is irregular in recurrence and 
in amount. It is observed especially at the times of the 
painful paroxysms, and a more or less profuse discharge of 
blood commonly attends the rupture of the fruit-sac. 

In ectopic pregnancy, as in normal gestation, a decidua is 
developed from the uterine mucosa. At the termination of 
the pregnancy the decidual membrane is expelled entire or 
piecemeal. This is distinguished by its histological charac- 
ters from the products of intra-uterine pregnancy and from the 
cast of endometritis. Under the microscope it differs from 
the former by the absence of evidence of implantation of 
chorial villi ; from the latter, according to certain authorities, 
by the presence of decidual cells, which are round or oval 
granular bodies, each containing a well-defined nucleus or 



PATHOLOGY OF PREGNANCY. 215 

several nuclei, and having a diameter five to fifteen times 
that of a red blood-corpuscle. 

Ovarian cyst, ovarian abscess, dermoid cyst, intraliga- 
mentous cyst, simple fluid accumulations in the tube and a 
retroverted and gravid uterus must be excluded. 

Differentiation from pregnancy in the rudimentary horn 
of a uterus unicornis is difficult or impossible ; but it is 
practically unnecessary, since the treatment is essentially 
the same in either condition. Left to themselves 80 per 
cent, of the latter class of cases terminate in rupture. As 
a rule no symptoms occur to arrest the attention of patient 
or physician before the uterus ruptures. 

Diagnostic Signs in the Later Months. The foetal 
movements are usually more distinct than in utero-gesta- 
tion; 

The foetal heart-tones are more intense ; 

The foetus is more accessible to palpation ; 

Ballottement is obtainable in the fourth and fifth months ; 

Shrinkage of the tumor usually ensues upon the death of 
the foetus ; 

The uterus can be differentiated from the tumor ; 

Most reliable in the later months is evidence of pregnancy 
with a uterus but little developed and distinguishable from 
the tumor. 

Signs of Primary Rupture. Cramp-like pelvic and 
abdominal pains, usually violent ; 

Irregular genital hemorrhage ; 

Symptoms of acute internal hemorrhage, with more or 
less collapse; 

The physical signs of pelvic hematocele or hsematoma; 

Evidence of moderate peritonitis within two or three 
days after rupture. 

In tubal rupture with much hemorrhage the clinical 



216 ESSENTIALS OF OBSTETRICS. 

picture is unmistakable. It is not so plain when the blood- 
loss is small. Abortion and dysmenorrhea sometimes simu- 
late very closely ruptured tubal pregnancy and these must 
be excluded. 

Intraperitoneal rupture is usually distinguished from 
extraperitoneal by more hemorrhage and by the physical 
signs of the free fluid in the pelvic peritoneum. The pres- 
ence of free blood, and even of soft blood-clots in the peri- 
toneal cavity, is difficult of recognition by the vaginal touch. 
When the blood effusion is encysted the condition cannot 
be distinguished from hematoma in the broad ligament. 
In intraperitoneal rupture a large, firm clot may be present 
in the tube, simulating a clot in the broad ligament. 

Extraperitoneal rupture is characterized by the presence 
of a circumscribed and more or less firm tumor (blood- clot) 
in one broad ligament as revealed by the vaginal touch. 
The blood collection may dissect up the peritoneum and 
burrow behind the uterus. Examination by the rectum and, 
if necessary, under anaesthesia facilitates the diagnosis. 

Before opening the abdomen, if the diagnosis cannot be 
otherwise established, the uterine cavity may be explored 
with the finger. It should not be forgotten that intra- and 
extra-uterine pregnancy may coexist. 

Treatment before Primary Rupture. 1 . Coeliotomy 
and removal of the pregnant tube. In the abdominal oper- 
ation the incision is made in the median line above the 
pubes large enough to admit the hand. The ovarian artery 
of the affected side is immediately clamped with catch-forceps 
close to the uterus, and again in the ovario-pelvic ligament just 
without the tube. Adhesions are broken up, the fruit-sac with 
the ovary and tube is lifted up and by a crescentic incision 
enough of the upper border of the broad ligament is cut 
away to carry with it the gestation-sac with the tube and 



PATHOLOGY OF PREGNANCY. 217 

ovary. The free ends of the divided artery and vein are 
now sought out and tied with finest catgut or silk between 
the folds of the peritoneum. The clamps are removed and 
the edges of the peritoneum whipped together with a run- 
ning suture of fine catgut. If preferred the more usual 
pedicle method may be adopted instead of the technique 
just described. 

In the latter method the fruit-sac, the ovary and the 
tube are lifted, and the entire tube with the ovary tied off 
close to the uterus. The pedicle is then divided about 
one-half inch distad the ligature. The cut end of the 
tube is cauterized, bloody oozing controlled, the peritoneum 
cleansed and the abdomen closed. 

2. Vaginal Incision. Removal of the pregnant tube by 
the vaginal route is sometimes practicable. Either the ante- 
rior or the posterior incision may be adopted. The technique 
is simpler in the latter. A half-inch incision is made trans- 
versely at the junction of the peritoneum with the uterus, 
usually 4 cm. (1^ inch) above the lower border of the cervix. 
The opening is then enlarged with the fingers. Tube and 
ovary are liberated, brought down into the vagina and tied 
off. The incision may be closed with sutures or be lightly 
packed with iodoform gauze to be left for three days. Oper- 
ation by vaginal incision, however, is rarely to be recom- 
mended. The work can be more safely and thoroughly 
done by the abdomen. 

3. Foeticide, by electricity or by the injection of drugs 
into the fruit-sac is no longer practised. 

Treatment after Rupture into the Peritoneum. Im- 
mediate coeliotomy. Method substantially as before rupture. 
The blood is removed from the peritoneal cavity and the peri- 
toneum irrigated with the normal salt solution — teaspoonful 
of salt to a quart of water previously sterilized by boiling. 



218 ESSENTIALS OF OBSTETRICS. 

A few quarts of the saline solution may be left in the 
peritoneum to help refill the vessels. In extreme anaemia 
and collapse a quarter grain of morphine may be given hypo- 
dermically a half hour before operating. If cceliotomy is 
refused the case must be trusted to rest with the use of 
sand-bags on the abdomen over the fruit-sac. 

Treatment after Eupture into the Broad Liga- 
ment. First three months. Limited effusions of blood do 
not necessarily require surgical interference. Should the 
cyst-contents become septic the sac should be opened, either 
by the abdomen or by the vagina. In the abdominal opera- 
tion the sac is evacuated, as much of it is removed as 
possible, the bleeding stopped, the remnant of the sac closed 
and drained through the vagina. A large hsematoma is 
generally best treated in like manner. 

When the suppurating sac is accessible by the vagina it is 
best opened and drained from below. 

If the ovum survives rupture of the tube into the broad 
ligament, it should be treated as a malignant growth by 
cceliotomy and extirpation of the fruit-sac. The life of the 
child in extra-uterine pregnancy is of too little value to weigh 
for a moment against the interests of the mother. 

After the third month. The foetus is in most instances 
still extraperitoneal. Cceliotomy and removal, if possible, 
of the entire ovum are indicated once the diagnosis is estab- 
lished. When the foetus has been dead for two of three 
months the placental vessels will be found obliterated and 
the complete extirpation of the sac is generally possible. 
Tying the ovarian artery on either side of the fruit-sac 
usually controls the hemorrhage. Moderate bleeding after 
removal of the placenta may be taken care of by packing 
the bleeding cavity firmly with iodoform gauze, the lower 
end of the abdominal incision being left open for one or two 



PATHOLOGY OF PREGNANCY. 219 

days. If the foetus is living no attempt should be made, as 
a rule, to remove the placenta. The sac may be stitched to 
the abdominal wall and the placenta left to separate, which 
usually occurs within a week or ten days. The recovery, 
however, is tedious, and attended with no little risk of sep- 
ticaemia. It is generally better to cut the cord short, remove 
the redundant portion of the sac-wall, close the sac without 
drainage and close the abdomen. A secondary laparotomy 
can be performed for removal of the placenta after its vessels 
are obliterated should it become necessary. 

Treatment of Interstitial Pregnancy. When the 
diagnosis is possible the pregnancy may sometimes be safely 
terminated by emptying the fruit-sac through the uterine 
cavity. On intraperitoneal rupture coeliotomy is indicated 
as in pregnancy in the free portion of the tube. Supra- 
vaginal amputation of the uterus may also be required. 

PERNICIOUS VOMITING OF PREGNANCY. 

Etiology. The hyperemesis of pregnancy is to a greater 
or less extent a neurosis. In many instances it is a reflex 
disorder, dependent upon some anatomical lesion of the 
pelvic organs, such as uterine displacement, detention of the 
uterus in the pelvis by adhesions or other cause, decidual 
endometritis, induration of the cervix, erosion or inflamma- 
tion of the cervix, or perimetritis ; yet it may occur inde- 
pendently of any discoverable pelvic disease. Lesions of 
other than the pelvic organs, and especially of the kidneys, 
may be complicating causes. 

Prognosis. In the majority of cases the nausea of preg- 
nancy subsides by the third or fourth month, when the 
uterus rises out of the pelvis. With persistent uncontrolla- 
ble vomiting the prognosis is grave. 



220 ESSENTIALS OF OBSTETRICS. 

Treatment, (a.) Dietetic measures. Useful dietetic 
measures are : Breakfast in bed, followed by sleep; an ounce 
of sherry wine or a small cup of strong coffee before rising, a 
glass of cold Vichy or carbonated water several times, daily ; 
to this sodium bromide is a useful addition, one drachm to 
the siphon. Other dietetic measures, such as are practised 
in ordinary vomiting, may be of service. The longings of 
the patient frequently afford a reliable guide to the feeding. 

Rectal alimentation must be relied on when stomach 
feeding is impossible. Beef blood, uncooked beef-juice, pep- 
tonized meat solutions, or predigested milk, §iv, q. 6 h., 
is a suitable food for the purpose. Five minims of deodor- 
ized tincture of opium may sometimes be added to the 
nutrient enemas with advantage. A large soft-rubber 
catheter or small rectal tube of similar material, with a 
funnel attached to the distal end, serves best for administer- 
ing the food injections. The tube should be well lubricated 
and passed high up in the rectum with care to avoid irritat- 
ing the bowel. The rectum should be washed out daily 
during rectal feeding. 

(b.) General therapy. Complete rest in bed for several 
days is frequently an important aid in controlling the vomit- 
ing. Useful drug measures are: Cocaine, gr. \ to \, repeated 
three or four times daily, or hourly until three or four doses 
are given ; cocaine spray to the pharynx or to the nares, 
1 per cent, solution ; chloral, gr. xx to xxx, in solution by 
the rectum, two or three times daily, best given in milk ; 
the bromide of sodium in similar doses. Morphine, in 
doses of gr. \ to J, hypodermically or endermically at the 
epigastrium is sometimes resorted to, especially when there 
is local tenderness. The after-effects of opium, however, 
are frequently bad. Strychnine, gr. fa to fa, or tincture of 
nux vomica, tt^v in water before meals, is indicated in 



PATHOLOGY OF PREGNANCY 221 

chronic gastric catarrh. Calomel, in single dose, gr. v to x, 
or in small repeated doses, gr. y 1 ^-, q. 1 h., often does valuable 
service. Oxalate of cerium, gr. x, q. 2 h., when it can be 
retained, or subnitrate of bismuth in similar doses may be 
tried. 

Ether spray to the epigastrium at the onset of each par- 
oxysm is sometimes effective. An ice-bag over the cervical 
vertebrae, or blister over the fourth and fifth vertebrae may help. 
Oxygen by inhalation has been used with success. A weak 
faradic current through the stomach sometimes relieves. 
Galvanism is thought to be of value. The anode is placed 
over the clavicle between the two branches of the sterno- 
cleido-mastoid muscle, the cathode over the umbilicus. The 
current strength should be 10 to 15 milliamperes continued 
for fifteen to thirty minutes. Other remedies such as are 
useful in vomiting from other causes may be found of service. 

(c.) Local measures. Cervical erosions should be touched 
with a twenty-grain solution of nitrate of silver every second 
day. Utero-displacements must be corrected. Sexual inter- 
course should be forbidden. 

Galvanism of the uterus is sometimes useful. The anode 
is applied to the cervix, the cathode over the lower dorsal 
vertebrae. A current of 3 to 5 milliamperes may be con- 
tinued for five minutes. The sitting is repeated morning 
and evening. 

A 10 per cent, cocaine solution freely applied over the 
portio vaginalis and within the cervix may relieve. 

Copeman's method of dilatation of the cervix below the 
os internum, either alone or in combination with the fore- 
going cocaine method, is one of the most reliable measures 
for relieving the reflex disturbance. This treatment may 
result in abortion, and should be adopted as one of the 
dernier ressorts. 



222 ESSENTIALS OF OBSTETRICS. 

Induction of abortion is indicated when other means fail. 
It should not be too long withheld. It is justified only when 
the mother's life would be seriously endangered by longer 
continuance of the pregnancy, and then only with the con- 
currence of counsel. 

Methods of Inducing Abortion. Partial separation of 
the ovum with a sound and packing the cervix with iodo- 
form gauze which is renewed every twelve to twenty-four 
hours are satisfactory methods. Either may be relied on or 
both may be combined. After the os internum is effaced 
the dilatation may be completed manually or instrumentally 
if the indication is urgent. 

In experienced hands the rapid method of evacuating the 
uterus with the curette and uterine dressing-forceps is gen- 
erally best. The cervix is first dilated with a steel branched 
dilator till the curette passes readily. The uterus can easily 
be emptied in ten or fifteen minutes. The patient should 
be under an anaesthetic. 

PTYALISM. 

Ptyalism like the nausea of pregnancy, with which it is 
usually associated, is a reflex disorder. Troublesome saliva- 
tion is comparatively rare. 

Treatment. Treatment is unsatisfactory. The follow- 
ing measures are sometimes of service : A saturated solution 
of potassium chlorate used several times hourly as a mouth 
wash ; sulphate of atropine, gr. -^ once to three times daily 
per os ; the bromides, gr. xxx to cxx daily. Salivation is 
usually most relieved by treatment which subdues the 
nausea. 

ANEMIA. 

Treatment. Blaud's pill, one or two t. i. d. ; arsenate 
of iron, gr. -^ to ^ t. i. d. ; albuminate of iron in full doses ; 



PATHOLOGY OF PREGNANCY. 223 

a solution of citrate of iron, gr. j hypoderaiically, are use- 
ful h^ematinics. A generous diet is essential. 

VARICES OF THE LOWER EXTREMITIES. 

They are frequently present in the later months of 
pregnancy. 

Treatment. The treatment consists in support with 
bandages or elastic stockings. Much standing is obviously 
injurious. 

PRURITUS VULV.E. 

Treatment. Place the patient in the Sims position, 
retract the posterior vaginal wall with a Sims speculum 
and dust the vaginal and vulvar surfaces with subnitrate 
of bismuth. Repeat daily or every two days. Fomenta- 
tions to the itching parts with plain hot water or with a '2h 
per cent, carbolic solution give temporary relief. Applica- 
tions of cocaine hydrochlorate are useful. If the pruritus is 
of diabetic origin treatment must be addressed to the cause. 



CHAPTEE VI. 

PATHOLOGY OF LABOR. 

ANOMALIES OF THE MECHANISM. 

A. ANOMALIES OF THE EXPELLING POWERS. 
1. Excess: Precipitate Labor. 

Cause. The cause of precipitate labor may be excessive 
activity of the expelling forces, or deficient resistance as in 
large pelvis or small head. 

Dangers. The dangers are for the most part insignifi- 
cant. The principal dangers to the mother are lacerations, 
especially in primiparse, shock and post-partum hemor- 
rhage ; to the child, asphyxia from the nearly continuous 
interruption of the utero-placental circulation, and the possi- 
ble accidents of sudden and unexpected birth, such as 
falling on the floor, precipitation into a water closet, rupture 
of the cord. 

Treatment consists in moderating the expelling forces 
by regulating the abdominal pressure, and, if required, by 
chloroform. The patient should be kept in bed from the 
onset of the pains. 

2. Deficiency: Prolonged Labor. 
I. Prolonged First Stage. Tardy Dilatation. 

(a.) Simple Inertia Uteri: Feeble Pains. 

Causes are emotional disturbance, full bladder or rectum, 
impaired muscular tone. Often the cause is obscure. 



PATHOLOGY OF LABOR. 225 

Treatment. In the absence of danger to mother or 
child the treatment should be expectant. Simple inertia 
uteri calls for no interference so long as the membranes are 
unbroken and the patient gets sleep and nourishment 
enough. The bladder and rectum should be evacuated 
frequently and other causes of inertia removed if possible. 

Measures for accelerating the first stage, when interfer- 
ence is required in the interests of one or both patients, are: 
Keeping the patient up and moving about, a hot sitz bath, 
a rectal injection of glycerin, §ss, the alternate use of hot 
and cold compresses over the abdomen, strychnine, gr. -^ 
to ^ every four hours hypodermically, to arouse the nerv- 
ous system, or quinine, gr. v to x, moderate stimulation 
with wine, whiskey or other alcoholic stimulants, the faradic 
current from the upper sacral region to the posterior vaginal 
fornix, peeling up the membranes from the lower uterine 
segment, the passage of an aseptic bougie between the 
membranes and the uterine walls, artificial dilatation with the 
hand or with water-bags. Interference within the passages, 
however, should generally be withheld if possible. 

(b.) Cramp-like Pains. 

The uterine contractions are painful but are inefficient, 
being more tonic than clonic. There is consequent failure 
of the normal changes in the lower segment and cervix 
which favor dilatation, even in the presence of apparently 
active pains. 

Causes are neurotic influences, excessive uterine disten- 
tion, as in hydramnios or twins, dry labor and the conse- 
quent unequable pressure upon the cervix, malpresentation, 
too firm adhesion of membranes at the lower uterine 
segment. 

Symptoms. The woman suffers excessive pain yet the 



226 ESSENTIALS OF OBSTETRICS. 

labor makes little or no progress. Mechanical obstruction 
must be excluded. The cervix is rigid, and if the mem- 
branes have ruptured the caput succedaneum is excessively 
developed. 

Dangers. Dangers are exhaustion in proportion to the 
severity of the pain and the loss of sleep and nourishment ; 
in dry labor, pressure-effects in both mother and child and 
septic infection. Atony of the uterus is liable to result. 
Exhaustion predisposes to a slow second stage. 

Treatment. Chloral, 5j in four doses of gr. xv each, 
at intervals of fifteen minutes, frequently does good service. 
Still more effective is opium, gr. j once or twice repeated, 
if necessary, at intervals of an hour. These narcotics may 
do either of two things : they may regulate the action of 
the expelling powers by abolishing in part the inhibitory 
influence of pain, or by inducing sleep they may invigorate 
the natural forces. 

Chloroform is very seldom permissible, except as an aid 
to surgical interference. Rupture of the membranes is indi- 
cated in marked hydramnios, peeling them up in undue 
adhesion. 

In dry labor gradual manual dilatation should be prac- 
tised under anaesthesia. When time permits Barnes' bags 
may be used, but when efficiency and rapidity are demanded 
the hand is better. Gentle traction with forceps may be 
tried after dilatation is nearly complete. 

Recourse may be had to multiple incisions of the cer- 
vix or to Diihrssen's incisions when immediate delivery is 
required. In the former method numerous shallow inci- 
sions are made in the lower border of the cervix with the 
scissors. The procedure is at once safe, simple and efficient. 
For the technique of Diihrssen's incisions the reader is re- 
ferred to the chapter on obstetric surgery. With a normal 



PATHOLOGY OF LABOR. 227 

head the space gained is sufficient for immediate delivery. 
Diihrssen's incisions are applicable only as a last resort. 

II. Prolonged Second Stage. 

Causes. The causes are most of those which operate in 
slow first stage. In addition may be mentioned exhaustion, 
pendulous abdomen, excessive uterine retraction — retraction 
ring more than half-way from the pubes to the navel, faulty 
action of the abdominal muscles. 

Symptoms. The evidence of inefficient pains is obvious. 
In neglected cases the temperature and pulse begin to rise 
and the vagina becomes hot and dry. Obstructed labor 
must be excluded. 

Dangers. Dangers to the mother are exhaustion and 
after rupture of the membranes, pressure-effects, sepsis. 
Vesico-vaginal or recto-vaginal fistulse may ensue from 
long-continued pressure of the head in the lower part of 
the birth-canal ; in neglected cases extensive sloughing of 
the vaginal walls may result. 

To the child the dangers are chiefly pressure-effects. The 
foetal mortality is large from intracranial hemorrhage due 
to asphyxia or occurring as the direct result of traumatism 
in instrumental delivery. Children who survive such in- 
juries are not infrequently crippled in mind or body or both. 

Treatment. Obstructive causes are excluded by pass- 
ing the hand into the uterus if necessary. The bladder 
and rectum should be evacuated. Uterine obliquity may 
be corrected by manual support, by posture or by the 
binder. Summon the help of the abdominal muscles. Give 
quinine, gr. x, strychnine, gr. -gL hypodermically, or alco- 
holic stimulants. Apply hot fomentations to the hypogas- 
tric or the sacral region. Put the patient in the semi- 
recumbent posture or squatting posture during the pains, 



228 ESSENTIALS OF OBSTETRICS. 

or let her sit on the edge of the bed. Ahlfeld's birth-stool 
may be tried. This consists of two stools so placed as to 
leave a triangular space between them opening to the 
front. The woman sits over the open space until the head 
is about to be born. 

Use expressio foetus, applying the pressure at the upper 
foetal pole or to the head only when the latter pole presents. 
Push aside intestinal loops and press downward in the axis 
of the inlet with one or both hands laid flat on the abdomen. 

Ergot in full doses is dangerous to the child and even 
to the mother. In large doses it tends to cause a persistent 
uterine contraction. In doses of ten minims of the fluid 
extract, repeated hourly, it merely increases the force and 
frequency of the natural labor pains. Its use is seldom 
permissible, never except in the absence of obstruction and 
in minute doses such as to produce normal uterine con- 
tractions. 

Forceps is indicated when the natural forces are clearly 
incompetent or longer delay would jeopardize the life of 
mother or child. As a rule interference is called for when 
the head has been arrested a half-hour, after two hours in 
the second stage, especially if the head is low down and 
there is no recession between the pains. Failure of reces- 
sion between the pains is evidence that the normal tonicity 
of the soft parts has been destroyed by prolonged pressure 
of the fcetal mass. 

B. ANOMALIES OF THE PASSAGES. 

I. Anomalies of the Hard Parts : Deformed Pelvis. 

Frequency. Contraction of some degree is present in 
from 10 to 15 per cent, of all parturients. The higher 
grades of deformity are fortunately rare. Moderate con- 



PA THOL OGY OF LAB OR. 22 9 

traction is by no means so. Among women born in this 
country contraction of the pelvis is very seldom met with. 
Moderate non-rachitic flattening, and general contraction, 
kyphotic and scoliotic deformity are most frequent. 

Gravity. The maternal and especially the foetal mor- 
tality are increased in proportion to the extent of deformity 
and the difficulty of delivery. 

The chief dangers are those of prolonged labor intensi- 
fied, to which are added those incident to operative inter- 
ference, malpresentation and malposition which occur more 
frequently than in normal pelves, and to prolapsus funis, 
rupture of the uterus and postpartum hemorrhage. 

The minor grades of deformity are dangerous for the 
most part to the child only. With early recognition and 
timely interference they usually present little difficulty. 

General Character of the Anomaly. Exception- 
ally the abnormity consists in faulty inclination only. In 
the majority of contracted pelves the narrowing is at the 
brim and is most frequently an antero-posterior flattening. 
Obstruction mav arise from old fractures, exostoses or other 
bony tumors. 

Description of Forms. 

Simple Flat Pelvis. This is the commonest variety of 
pelvic contraction. It consists simply of antero-posterior 
flattening. The intercristal and the interspinal diameters 
have the same value as in the normal pelvis or may be 
slightly increased. Their relation is the same as in the 
normal pelvis or nearly so. The circumference may or 
may not be diminished. The true conjugate seldom falls 
below three inches. The other internal diameters are not 
affected. 

In this form of pelvic anomaly the woman is usually of 

11 



230 ESSENTIALS OF OBSTETRICS. 

full stature and her general appearance presents no evidence 
of deformity. 

Influence on the Mechanism of Labor. The head 
passes the brim with its long (occipito-frontal) diameter in 
the transverse of the pelvis and with the sagittal suture 
level or nearly so. Below the brim the head-movements 
are the same as in the normal pelvis. 

Flattened and Generally Contracted Pelvis. This 
pelvis is contracted in all its diameters, but especially in 
the conjugate at the brim. Its cause is arrest of develop- 
ment affecting the innominate bones and the lateral masses 
of the sacrum. The promontory of the sacrum is higher, 
and the diagonal conjugate therefore longer, than normal 
notwithstanding the shortening of the true conjugate. 

Justo-minor Pelvis: Pelvis -ffiquabiliter Justo- 
minor. This, as its name implies, is a generally con- 
tracted pelvis. Its diameters are not in all cases uni- 
formly contracted. In occasional instances the narrowing 
is confined chiefly to the outlet. The justo-minor pelvis 
is most frequent in women of small stature. Yet its size 
bears no relation necessarily to the size of the woman's 
body. This is a common form of contraction. It is due 
to arrest of development. 

Funnel-shaped Pelvis or Male Pelvis. The pelvis 
is narrowed at the outlet ; the tubera ischiorum are approxi- 
mated ; the antero-posterior diameter at the outlet may be 
shortened. The subpubic angle is narrow. The sacrum is 
long and but little curved. The deformity is exceedingly 
rare. 

Kyphotic Pelvis. The upper end of the sacrum is 
tilted backward. The pelvic inclination is diminished. 

The transverse diameter is increased in the false pelvis, 
somewhat diminished at the inlet of the true pelvis, and 



PATHOLOGY OF LABOR. 



231 



the conjugate is lengthened. The pelvis is funnel-shaped ; 
the ischial spines are strongly approximated. The sacrum 
is narrowed, its longitudinal curvature diminished, its trans- 
verse curvature is increased, its lower end is displaced for- 
ward. The pubic arch is narrow, the symphysis is promi- 
nent. The cause of the deformity is kyphosis in the 
lumbo-sacral region. 

Naegele Oblique Pelvis : Ankylosed Obliquely Con- 
tracted Pelvis. There is complete or partial absence of 
one lateral mass of the sacrum, generally ankylosis of the 

Fig. 54. 




Naegele pelvis. 



corresponding sacro-iliac joint and narrowness of the cor- 
responding half of the pelvis ; the opposite side is increased 
in size. The shape of the brim is an oblique oval ; the 
symphysis is not opposite the promontory. The walls of 



232 



ESSENTIALS OF OBSTETRICS. 



the pelvic cavity converge below, the sacrum is asymmet- 
rical and the pubic arch narrow. This variety of deformity 
is very rare. (Fig. 54.) 

Ordinary Oblique-ovate Pelvis. The shape is similar 
to that of the Naegele pelvis, but the deformity is due to 
coxitis ; the contraction is on the side opposite the crippled 
member. 

Roberts Pelvis. In the Roberts pelvis there is com- 
plete or partial absence of both lateral masses of the sacrum. 
The conjugate is somewhat diminished. The subpubic angle 
is narrow. The deformity is exceedingly rare. 

Fig. 55. 




Section of spondylolisthetic pelvis. 



Spondylolisthetic Pelvis. The anomaly consists in a 
gliding forward of the last lumbar on the first sacral verte- 



PATHOLOGY OF LABOR. 233 

bra. The inferior surface of the former ultimately rests 
upon the anterior surface of the latter and becomes firmly 
united to it. Shortening of the antero- posterior diameter 
at the brim is extreme. Spondylolisthesis is very rarely 
met with. (Fig. 55.) 

Osteomalacic Pelvis. In osteomalacia the deformity 
arises from softening of the bones and consequent yielding 
in the direction of the existing pressures. The osteomalacic 
pelvis is, accordingly, sometimes termed the compressed 

Fig. 56. 




Osteomalacic pelvis. 

pelvis. The pubic portion of the pelvis is beak-shaped. 
The sacrum is convex from above downward and from side 
to side. The bisischial diameter is increased. (Fig. 56.) 

This is one of the rarest forms of contraction. 

Narrowing of the Pelvis from Bony Tumors. Ob- 
struction of this form comprises simple exostoses, callus 
and displacement of bones due to fracture. 



234 ESSENTIALS OF OBSTETRICS. 

Diagnosis of Pelvic Deformity. 

Clinical data. Evidence of rachitis in infancy, such as 
history of tardy dentition and of sweats, pigeon-breast, 
curvature of the tibiae, of the spine, or other asymmetry of 
the body, large joints, very low stature are significant of 
probable deformity. Disability of one lower extremity 
dating from infancy is almost surely attended with pelvic 
contraction. A pendulous abdomen, presenting pole per- 
sistently above the excavation during labor, deformities in 
near relatives or a history of difficult labors should excite 
suspicion. 

Pelvimetry. The only means of exact diagnosis is the 
measurement of the pelvic diameters. Frequently the pel- 
vis will be found contracted with no other evidence of any- 
thing abnormal than that afforded by pelvimetry. (See 
pages 131 et seq.) 

The pelvis should be carefully examined by palpation 
with reference to its shape and symmetry. 

Most essential is the measurement of the external con- 
jugate, the interspinal and the intercristal diameters exter- 
nally, and of the diagonal conjugate and the diameters of the 
outlet internally. The transverse and the oblique diameters 
at the brim are estimated with the hand in the passages. 
The shape and size of the sacrum, the presence or absence 
of bony tumors and the general conformation of the pelvis 
are to be determined by external and internal palpation. 
The pelvic inclination should also be estimated. 

In most cases the value of the external conjugate decides 
the question whether or not the pelvis is ample, since in 
nearly all forms of narrow pelvis the conjugate is diminished. 
As a rule, with an external conjugate below 17.5 cm. (7 
inches) the internal conjugate is small ; external conjugate 



PATHOLOGY OF LABOR. 235 

above 7 inches the internal conjugate is ample. Yet ex- 
ceptionally the internal diameters of the brim may be nor- 
mal when the diameter of Baudelocque .is no more than 
16.5 cm. (6J inches), and on the other hand actual contrac- 
tion may exist when the external conjugate measures 19 
cm. (7J inches) or even more. 

It must not be forgotten that the size of the foetal head is 
no less important a factor in the difficulty of delivery than 
is the capacity of the pelvis. The size of the head must, 
therefore, also be taken into account. The head measure- 
ments cannot be so accurately determined as those of the 
pelvis. An approximate estimate is possible by measuring 
the accessible diameters of the head through the abdominal 
walls with a pelvimeter. It is also useful to try how far 
the head can be made to enter the brim by crowding it 
down with one hand over the lower part of the abdomen, 
while the fingers of the other hand passed internally esti- 
mate the depth of descent. When necessary for determin- 
ing the size of the head during labor the half-hand should 
be introduced into the uterus. 

Management of Labor in Flat Pelvis. 

Conjugate, 9 cm. (3 J inches) or more. The spontaneous 
delivery of a living child is generally possible. The mem- 
branes should be preserved by colpeurynter if required. 
Malpositions must be corrected. The bladder and the 
rectum should be emptied. 

When nature fails delivery may be effected by : 

1. Forceps, provided the head is engaged and the child 
living and viable. The forceps operation is here much more 
dangerous to mother and child than in the normal pelvis ; 

2. Podalic version, when the head is not engaged, the 
child is alive and viable and other conditions are favorable ; 



236 ESSENTIALS OF OBSTETRICS. 

3. Craniotomy, as a rule, if the child is dead ; version 
or forceps may be chosen in easy extractions. 

Premature labor. The induction of premature labor at 
the thirty-sixth or thirty-seventh week should generally be 
preferred to forceps or version at term if the conditions are 
discovered in time. 

Conjugate, 1 to 9 cm. (2| to 3J- inches). When the foetus 
is alive and viable symphysiotomy should be preferred ; 
when dead or non-viable podalic version or craniotomy is 
to be chosen. 

Artificial premature labor at or soon after the end of the 
eighth calendar month should be considered when the con- 
traction is recognized in time. 

Conjugate, 7 cm. (2f inches) or less, absolute contraction. 
At term the Csesarean section or the Porro operation is in- 
dicated. When the deformity is known in time the induc- 
tion of abortion should be considered. 

The choice of procedure, however, in narrow pelvis, must 
be determined by the relative, not alone by the actual size 
of the pelvis ; the degree of disproportion between the head 
and the pelvis must decide. The size of the head may be 
estimated by the method just detailed. 

Management of Labor in other Pelvic Deformities. 

The method of delivery must depend upon the kind and 
degree of obstruction. At term version or forceps is com- 
petent in a small percentage of cases. The possibility of a 
living birth by induced labor should be considered when 
the condition is discovered in time. 

Symphysiotomy is applicable when the conjugate is above 
three inches and there is but little contraction in other 
diameters. Usually craniotomy best serves the interests of 
the mother if the foetus is dead or non-viable. In the 



PA THOL OGY OF LAB OB. 237 

higher grades or disproportion, the Cesarean or the Porro 
operation is indicated. 

In excessive pelvic inclination the woman should be 
placed on the side to favor engagement of the head. 

When the pelvic inclination is diminished the liability 
to injuries of the pelvic floor is greater than in normal 
conditions. 

II. Anomalies of the Soft Parts. 

Vulvar Atresia. Atresia may result from inflammatory 
adhesions of the labia majora, oedema vulvae, thrombus, car- 
cinoma, simple rigidity of the pelvic floor or rigidity of the 
hymen. 

Treatment. A large thrombus may require incision, 
evacuation of the blood-clots and packing the cavity. 
Nature or forceps is usually competent. A rigid hymen 
may call for single or multiple incisions. Other forms 
of rigidity, as a rule, can be trusted to forceps with, perhaps, 
episiotomy. 

Vaginal Atresia. Two varieties are recognized, con- 
genital and acquired. The narrowing may be annular or 
may involve the whole length of the canal. In the annular 
variety multiple incisions and forceps will generally be re- 
quired ; in complete atresia the Cesarean or Porro opera- 
tion is the only resource. 

Cystocele. The treatment consists in replacing the pro- 
lapsed bladder-wall after catheterizing. Evacuation by the 
catheter being impossible, the bladder may be aspirated 
through the vaginal or the abdominal wall. 

Rectocele is replaceable with the aid of the Sims or the 
genupectoral position. It is rare that delivery is compli- 
cated with prolapse of the vaginal walls. 

Rigidity of the Cervix may arise from atrophic changes 

11* 



238 ESSENTIALS OF OBSTETRICS. 

in aged primiparae, from hypertrophy of the portio vagina- 
lis or from cicatrices. The dilatation is to be left to nature 
except in the presence of danger to mother or child. Arti- 
ficial measures, if required, are Barnes' bags, manual dila- 
tation, multiple shallow incisions about the free border of 
the cervix, rarely deep cervical incisions. Good results 
have been claimed for a 10 per cent, solution of cocaine 
applied to the os uteri. 

Cancer of the Cervix. The induction of premature 
labor, cervical incisions through the healthy tissue with a 
thermo-cautery knife and extraction with forceps are the 
principal measures for delivery in the later months. The 
passages should be repeatedly irrigated with an antiseptic 
solution during and after labor. Mercurials, however, must 
not be used. 

When the entire cervix is involved, and especially when 
the growth has extended higher in the uterus, Cesarean 
section will be required. It is best done before labor is 
spontaneously established. The entire uterus may be re- 
moved if the disease has not extended beyond the uterus 
and the condition of the mother permits. When the disease 
is detected in the early months hysterectomy should be con- 
sidered. 

Occlusion of the Os Externum. The os is reopened 
by incision from behind forward. If the depression cor- 
responding to the os can be found with the finger, a small 
opening may be made with a knife and extended with scissors 
or stretched with the fingers or with a branched steel dilator. 

Tumors. Treatment, (a.) Vesical calculi may be re- 
placed, or, this being impossible, removed by vaginal 
lithotomy. 

(b.) Vaginal tumors. Removal, if practicable, is indi- 
cated, otherwise Cesarean section or the Porro operation. 



PATHOLOGY OF LABOR. 239 

(<?.) Uterine tumors. Pedunculated tumors, when easily 
movable, may sometimes be pushed above the head with the 
aid of the genu-peetoral or the Trendelenburg position, or 
removed with ecraseur or scissors. The Cesarean or the 
Porro operation may be required. 

(<f.) Ovarian cysts. Generally ovariotomy is indicated 
immediately on discovery of the tumor. During labor re- 
position should be tried, or aspiration through the vaginal 
fornix may be permissible. Cesarean section is the only 
alternative when reposition fails and aspiration is not 
deemed advisable. The tumor is removed at the same time. 

Developmental Anomalies of the Uterus. 

Uterus Unicornis. One lateral half is absent ; there is 
generally but one Fallopian tube. This malformation arises 
from failure of development in one of Miiller's ducts. It 
is of special obstetric interest from the fact that the uterus 
sometimes has a rudimentary horn on the defective side in 
which pregnancy may occur. The condition is then very 
similar to tubal pregnancy. The rudimentary horn usually 
ruptures. Pregnancy in the developed horn of a uterus 
unicornis does not differ essentially from normal gesta- 
tion. 

Uterus Didelphys. A bifid uterus ; each lateral half 
forms a distinct organ, representing, however, but one-half 
of a uterus. The ducts of Miiller, instead of fusing as 
they normally do to form the uterus, do not even come in 
contact with each other. The vagina may be single or 
double. 

Uterus Bicornis. The lateral halves are distinct above, 
united below — the upper part of the uterus is bifid. The 
ducts of Miiller are developed, but are not united in the 
parts corresponding to the upper portion of the uterus. 



240 ESSENTIALS OF OBSTETRICS. 

The uterine cavity is sometimes divided wholly or partially 
by a median septum. The vagina may be single or double. 

Uterus Oordiformis. The fundus presents an antero- 
posterior median sulcus. 

Uterus Septus. The uterine cavity is divided, wholly 
or partially, into two lateral cavities by a median partition. 
When the septum extends through the length of the uterus 
the condition is termed uterus septus duplex. When the 
division is incomplete we have a uterus subseptus. Exter- 
nally the organ betrays no evidence of the abnormity. In 
all double uteri pregnancy may occur in either or both 
lateral divisions. Pregnancy in either causes the develop- 
ment of a decidua in each. 

C. ANOMALIES OF THE PASSENGER. 
Occipito-posterior Position. 

In most cases occipito-posterior positions terminate as 
anterior positions by rotation either above the brim, in the 
cavity or at the vaginal outlet. Exceptionally the sinciput 
rotates to the pubes and the head is born with the face to 
the pubic arch. In this position the expelling forces act at 
a disadvantage ; the long diameter of the head does not 
conform fully to the axis of the pelvis and labor is impeded. 
In persistent posterior positions of the occiput the head 
not infrequently becomes arrested by impaction in the 
pelvis. An impacted occipito-posterior position is one of 
the most formidable varieties of foetal dystocia. 

Causes. The causes of anterior rotation of the sinciput 
are : Imperfect flexion, bringing occiput and sinciput to the 
pelvic floor at about the same time ; defective resistance 
of the pelvic floor and consequent failure of the mechanism 
which normally shunts the occiput forward ; certain pelvic 



PATHOLOGY OF LABOR. 241 

deformities, especially general contraction, oblique deform- 
ity and kyphotic pelvis, disturbing the normal mechanism. 

Diagnosis. Abdominal signs. No dorsal plane ; small 
parts in middle section of the abdomen ; cephalic prom- 
inence marked ; heart-tones heard over lateral aspect of 
abdomen well toward the back. Anterior shoulder remote 
from the median line. 

Vaginal signs. Large fontanelle easily accessible to the 
examining finger indicates either an occipito-posterior posi- 
tion or an imperfectly flexed anterior position. They are 
distinguished by the relative situation of the fontanelles. 

Daxgers. The dangers in persistent occipito-posterior 
position are: To the mother/exhaustion, pelvic floor lacera- 
tions, the risks of operative interference ; to the child, those 
of prolonged labor. The foetal mortality is 15 per cent. In 
a relatively large pelvis the malposition is practically un- 
important. 

Treatment, (a.) Above the brim. Before rupture of the 
membranes the patient should lie in a lateral or latero-prone 
position on the side which the occiput confronts; anterior 
rotation of the dorsum is thus often possible. The genu- 
pectoral position still more effectually helps the normal 
mechanism. Rotation failing, after sufficient dilatation 
correct the malposition by combined internal and external 
manipulation. One hand on the mother's abdomen pushes 
the anterior shoulder inward toward the median line ; the 
fingers of the other passed into the uterus push the pos- 
terior shoulder of the foetus in the opposite direction. In 
this manner the child's dorsum, as well as the occiput, is 
brought to the front and there is no tendency to recurrence 
of the malposition. When the head alone is rotated it 
almost invariably reverts to its former position. 

(b.) In the cavity. Anterior rotation of the occiput may 



242 ESSENTIALS OF OBSTETRICS. 

be favored by keeping the patient upon the side to which 
the occiput looks, by upward pressure against the sinciput 
during the pains to promote flexion, sometimes by assisting 
rotation manually. If the head becomes arrested axis- 
traction forceps should be tried cautiously. When the head 
is immovably fixed symphysiotomy may be considered. 

(c.) At the vaginal outlet it is almost always possible to 
rotate the occiput into anterior position by backward press- 
ure with the fingers against the anterior temple, combined 
if necessary with forward pressure upon the occiput. Only 
rarely must the head be delivered in the occipito-posterior 
position. 

Face Presentation. 

Frequency. The frequency of face presentation is about 
one in two hundred and fifty labors. 

Causes. The extension of the head is probably never 
primary, it is developed during the labor. The causes are : 
Narrow pelvis, narrowing of the brim by prolapsed extrem- 
ity, large child, enlargement of the neck or thorax, excessive 
uterine obliquity, pendulous abdomen, preternatural mobility 
of the foetus owing to small size or to excess of liquor amnii, 
impaction of the occiput in occipito-posterior position. The 
preponderance of left mento-anterior positions is due to the 
right obliquity of the uterus. 

Mechanism. The occipito-mental diameter is in rela- 
tion with the axis of the birth- canal, but that diameter is 
inverted, the head descending mental pole first. The 
values of the engaging diameters of the head are substanti- 
ally the same as in vertex presentation. The difficulty of 
face births is due in the main to the fact that the thickness 
of the neck and a portion of the chest is added to the 
diameter of the face as the head descends, making a total 
diameter of 6J inches. 



PATHOLOGY OF LAB OB. 243 

Positions : 

Left mentoanterior — L. M. A. 
Right mento- anterior — R. M. A. 
Right mento-posterior — R. M. P. 
Left mento-posterior — L. M. P. 
Mechanism of Mento -anterior Positions: Head Move- 
ments. 1. Extension. This corresponds to flexion in ver- 
tex births, bringing the occipito-mental diameter more 
nearly in relation with the axis of the pelvis. 

2. Rotation. Rotation of the chin under the pubic arch 
unlocks the difficulty of face birth. Failure here is more 
serious than in vertex presentation. The mechanism of 
rotation is entirely similar to that in vertex births [mutatis 
mutandis). 

3. Flexion corresponds to extension in vertex presen- 
tation. The lower surface of the inferior maxilla rests on 
the margins of the ischio-pubic rami as pivotal points, and 
the head is expelled by a movement of flexion, face, fore- 
head, vertex, and occiput sweeping in succession over the 
perineum. 

4. Restitution. 5. External rotation. The explanation 
of these two movements is the same as in vertex births. 
The birth of the trunk follows the same mechanism as 
in vertex presentation. 

Mechanism of Mento-posterior Positions. In typical 
size of head and pelvis the birth of a persistent mento- 
posterior position is impossible, since it would necessitate 
the passage of a diameter of 6J inches through the pelvis. 
Anterior rotation takes place in the majority of cases. 

Diagnosis. Abdominal signs : Hour-glass shape of the 
uterus ; cephalic tumor very round and filling one side of 
the pelvis only ; cephalic prominence in relation with the 
foetal dorsum, and generally on the same side of the median 



244 ESSENTIALS OF OBSTETRICS. 

line with the breech ; sulcus at the junction of the head and 
back ; heart and small parts on the same side ; inferior 
maxilla accessible to palpation. 

Vaginal signs : Orbital ridges ; nasal bones ; malar 
bones ; alveolar processes ; chin. 

Prognosis. Mento-anterior face cases and mento- 
posterior that rotate terminate spontaneously, as a rule, 
with little more danger to mother or child than vertex 
births. The more formidable difficulties of face birth arise 
chiefly from its complications. Disproportion between head 
and pelvis, prolapse of foetal members and failure of the 
pains are met with more frequently than in normal pre- 
sentation. The total mortality is about 6 per cent, of the 
mothers and 10 per cent, of the children. The face of the 
child at birth is usually much disfigured. 

The principal dangers to the mother are exhaustion and 
pressure-necrosis ; to the child, cerebral congestion from 
obstructed circulation in the veins of the neck. Rotation 
failing nearly all the children die. 

Treatment. Nature is competent in most mento-anterior 
positions and in most mento-posterior positions that rotate. 
In cases seen before engagement of the face, however, or 
when the head can be pushed above the brim with the aid 
of the lateral, the knee-chest or the Trendelenburg posture, 
as a rule the malpresentation should be corrected. In cer- 
tain cases of posterior position it will be sufficient to reduce 
the position to a simpler one. The membranes should be 
preserved if possible until full dilatation. 

Mento-anterior Positions. In the absence of compli- 
cations conversion into vertex, while permissible, is by no 
means imperative. These cases may generally be safely 
conducted as face births. Rotation is favored by keeping 
the patient on the side to which the chin points. Should 



PA THOL OGY OF LAB OB. 245 

the pains fail deliver with forceps. Since the conversion 
of a mento-anterior face case into a vertex presentation 
results in an occipito -posterior position, if this method be 
chosen the operation should be supplemented by rotating 
the foetus into an anterior position. 

Head relatively large, or cord or arm prolapsed, podalic 
version is generally demanded. 

Mento-posterior Positions not too firmly engaged should, 
as a rule, be converted into vertex presentations by one 
of the methods described below. Reduction of the posi- 
tion into a mento-anterior position may suffice in the ab- 
sence of complications. This is usually possible with the 
hand in the uterus, the trunk being rotated at the same time 
with the head. In disproportion between head and pelvis 
and in prolapse of the cord or an arm the same rule applies 
as in mento-anterior positions. 

When the face is too deeply engaged for reduction rota- 
tion may be favored by the lateral posture, by promoting 
extension and by drawing the chin downward and forward 
during the pains. 

Forceps in mento-posterior positions of the face is one of 
the most difficult and dangerous of instrumental deliveries, 
especially for the child. 

Face immovably fixed, foetus living, deliver by symphysi- 
otomy ; foetus dead, by craniotomy. 

Methods for Converting Face into Vertex Presentation. 

1. Sehatz. This consists in pushing the breech forward 
(toward the feet) with one hand, the chest backward and 
upward with the other, by external manipulation, and finally 
crowding the foetus downward in the axis of the pelvis. 
It is applicable only before rupture of the membranes and 
even then is not always practicable. (Fig. 57.) 



246 



ESSENTIALS OF OBSTETRICS. 



2. Baudelocque. (1.) Flexing the head by pushing up- 
ward with the fingers first against the chin, then the fossae 
caninse, then the brow, with one hand internally, the ex- 
ternal hand assists by forcing down the occiput. (2.) 
Hooking down the occiput with the internal hand the ex- 
ternal hand pushes up the chest. Anaesthesia is generally 
required. (3.) Baudelocque's first method may be combined 
with Schatz's, with the help of an assistant (Ziegenspeck). 



Fig. 57. 




Schatz method of reducing face to vertex presentation. 

The genu-pectoral or the Trendelenburg position greatly 
facilitates the foregoing manipulations. 



Brow Presentation. 

Brow presentation is a partial or semi-extension of the 
head. It is rarely met with, generally undergoing spon- 
taneous conversion into vertex or face. By many obstetri- 
cians this anomaly is treated not as a distinct presentation, 
but as a variety of face presentation. 

The positions are those of face presentation. 



PATHOLOGY OF LABOR. 247 

Causes. The causes are substantially the same as in 
face presentation. 

The Frequency may be estimated at about 1 in 1800 
labors. 

Diagnosis. Abdominal signs : The same as in face 
presentation but imperfectly developed. 

Vaginal signs : Orbital ridges within touch on one side, 
bregma on the other side of the presenting part. 

Prognosis. Delivery in persistent brow cases is impos- 
sible except with a relatively large pelvis. The maternal 
mortality is 1 : 10, the foetal 1 : 3. 

Treatment, (a.) Conversion into vertex. Before en- 
gagement convert into vertex by seizing the head, pushing 
it up and hooking down the occiput, with the hand in the 
vagina and with the aid of anaesthesia. During the manipu- 
lation the fundus is supported by firm pressure with the 
external hand. Pressure upon the occiput, applied through 
the abdominal wall, helps. 

(b.) Conversion into j ace by traction on the upper maxilla 
with the fingers. This is not admissible in mento-posterior 
positions. 

(c.) Version for rapid delivery, if indicated in the in- 
terest of mother or child and the head is not engaged or 
the uterus is not firmly contracted. 

(c?) Symphysiotomy in impacted and irreducible brow 
presentation if child is living and viable, if dead crani- 
otomy. 

In general the same principles apply as for the manage- 
ment of face births. 

Breech Presentation. 

Varieties. Three varieties of breech presentation are 
recognized according to the part of the pelvic extremity 



248 ESSENTIALS OF OBSTETRICS. 

which presents — breech, knee and footling. The distinction 
is of no practical importance so far as the mechanism is 
concerned. In certain cases, however, as will be seen, it 
affects the question of treatment. 

Frequency. Exclusive of premature labors, the fre- 
quency of breech presentation is about 1 in 60 births. 

Causes. The causes are : Narrow pelvis, tumors of the 
uterus, placenta prsevia, hydrocephalus, multiple foetus and 
conditions favoring the mobility of the foetus, such as multi- 
parity, prematurity, lax uterine walls, hydramnios, shape 
of the uterus possibly, small foetus. 

Mechanism. Usually the bisiliac diameter engages in 
one of the oblique diameters of the pelvis. We have, 
therefore, four 

Positions : 

Left sacro-anterior — L. S. A. 
Right sacro-anterior — R. S. A. 
Right sacro-posterior — R. S. P. 
Left sacro-posterior — L. S. P. 

Rotation in breech is not so pronounced as in head pre- 
sentation. As the breech ;descends the posterior hip first 
lands upon the pelvic floor and first appears at the vulva. 
The shoulders rotate more or less completely. The head 
rotates as perfectly as in vertex births. In dorso-pos- 
terior positions the occiput, as a rule, comes eventually 
to the front. The nape of the neck resting against the 
pubic arch, the head is expelled by a movement of flexion 
around this as a pivot, the face, the forehead and the 
vertex successively sweeping over the perineum. Spon- 
taneous expulsion of the after-coming head, however, is 
exceptional. 

In persistent dorso-posterior positions the head is gen- 
erally delivered by a movement of rotation about the edge 



PATHOLOGY OF LABOR. 249 

of the perineum, mental pole first as in anterior positions. 
If the chin catches upon the pelvic brim delivery is accom- 
plished occiput first. In this method of expulsion the 
lower surface of the inferior maxilla pivots against the 
pubic bones, and occiput, vertex, forehead and face sweep 
in succession over the perineal edge. 

Diagnosis. Abdominal signs: 1. Fundal pole hard, 
globular, susceptible of ballottement, sulcus between it and 
the trunk ; 

2. Lower pole irregular in shape, not so hard, in primi- 
pane above the excavation before labor. 

When the head is in the lower uterine segment ballotte- 
ment is possible only in multipara and with excess of liquor 
amnii; even then it is imperfect. In primiparse in the 
absence of pelvic contraction and of obstruction from 
tumors or other causes, the head, when it presents, is found 
in the excavation. 

Vaginal signs : Glove-finger protrusion of the bag of 
waters ; 

Absence of the hard globular head ; 

Absence of fontanelles and sutures ; 

Ischial tuberosity ; 

Tip of the coccyx, anus, genitals, on a line bisecting the 
bisischial line at a right angle. 

Femora ; 

Expulsion of meconium — not diagnostic ; it is sometimes 
observed in cephalic births. 

Glove-finger protrusion of the membranes obviously can 
be present only after labor has been for some time estab- 
lished. Frequently both ischial tuberosities may be reached, 
and from them the femora be traced for a short distance. 

Identify a foot, knee, shoulder, elbow or hand by its 
anatomical characters. 



250 ESSENTIALS OF OBSTETRICS. 

In differentiating between head and breech do not rely 
on a mere casual touch. Every accessible part of the pre- 
senting pole must be searched minutely, and with firm 
pressure if impacted in the excavation and its bony land- 
marks obscured by cedematous swelling of the overlying soft 
structures. 

Prognosis. To the mother. The first stage of labor 
may be more tedious. The second stage is often more 
rapid. In artificial delivery laceration of the cervix occurs 
more frequently than in vertex births ; in first labors at 
least laceration of the pelvic floor is the rule. The danger 
to life is not increased. 

To the child. The mortality, when the delivery is left to 
nature, is one in three or four ; with skilled management it 
is but little greater than in vertex births. 

The cause of the foetal mortality is asphyxia from impeded 
blood- supply due to retraction of the uterus after the birth of 
the trunk, and from compression of the, funis after the head 
engages. The foetal mortality is increased in dry labor. 

Indications of danger to the child at the critical moment, 
in breech delivery, are : funic pulse irregular and feeble, 
occasional gasping respiratory efforts, convulsive movements 
of the limbs. 

Treatment. Before labor. External version is permis- 
sible if it can be done without violence. While conversion 
into vertex presentation is desirable, the indication for chang- 
ing the presentation before labor is not sufficiently urgent 
to justify the risk involved in a difficult external version. 

During labor, (a.) Delivery of the trunk. The danger 
to the child arises chiefly from the difficulty of delivering 
the after-coming head before the child perishes from arrest 
of circulation in the umbilical cord by pressure. Undeliv- 
ered the child will almost surely die within five minutes 



PATHOLOGY OF LABOR. 251 

after the head engages and the uteroplacental circulation is 
cut off. The delivery of the after- coming head is facilitated 
by : (1.) Ample dilatation of the passages ; (2.) Full flexion 
of the head, which also tends to maintain the flexion of the 
arms. 

Promote 1 by preserving the membranes till they reach 
the pelvic floor and, as a rule, by a slow and gradual de- 
livery of the breech ; maintain 2 by avoiding traction till 
the trunk is delivered, or, when traction is unavoidable, by 
external manipulation so applied by a skilled assistant as to 
keep the chin firmly pressed against the chest. 

Bringing down a foot. When the case is seen before 
the breech has too firmly engaged in the excavation one 
foot should be brought down. This is done as a precaution 
against arrest of the breech in the pelvis. The leg serves 
as a tractor should the expellent forces fail. 

(b.) Delivery of the arms and head. Preliminaries. 
The patient, as a rule, should be under an anaesthetic. 
Have the forceps ready. See that a flannel or towel is in 
readiness for wrapping the child's body as soon as it is ex- 
pelled, in order to prevent premature efforts at respira- 
tion. Watch the pulsation of the funis for warning of 
danger to the child. Pull the cord down and dispose it if 
possible in that part of the pelvis which offers the most room. 

Extraction of the Arms, (a.) Arms flexed. Bring them 
down with the hand passed along the child's abdomen. 

(b.) Arms extended. 1. Delivery of the first arm. As 
soon as the shoulder-blade can be easily reached, grasp the 
feet and draw the trunk to the side opposite the occiput. 
Bring down the posterior arm first. Pass the free hand up 
along the child's back and slip one or two fingers over the 
shoulder and along the humerus to the elbow. Sweep the 
elbow in a circular direction across the face and down. 



252 ESSENTIALS OF OBSTETRICS. 

Beware of applying the force at the middle of the humerus 
and of attempting to bring the arm straight down, lest the 
humerus be fractured or the shoulder-joint injured. 

2. Delivery of the second arm. Bring the child's trunk 
into the long axis of the mother's body, seize Jhe trunk 
with both hands and push it up to release the head and ex- 
tended arm from the grasp of the pelvic brim ; rotate the 
trunk, if necessary, to carry the undelivered arm opposite 
the nearest sacro-iliac joint. Assist rotation by drawing 
the delivered arm gently across the child's back. Then, 
holding the trunk to the opposite side, bring down the 
second arm, sweeping the elbow inward across the face 
and downward as in case of the first arm. It is seldom 
that rotation of the head fails by twisting the trunk as 
above described. Should it do so from the fact that the 
head has been driven too far into the pelvis the manoeuvre 
mentioned by Kehrer may be tried. This consists in push- 
ing the occiput outward with the external hand while the 
face is swept inward with the arm by the internal hand. 

Extraction of the after-coming head. I. I) or so- anterior 
'positions. Seizing the trunk again with both hands rotate 
the head, if necessary, to bring the face opposite one of the 
sacro-iliac joints. 

Smellie- Veit (Mauriceau) Method. Two fingers of one 
hand are passed within the passages and held firmly against 
the fossae caninae or the inferior maxilla to maintain com- 
plete flexion. Two fingers of the other hand are hooked 
over the shoulders astride the neck. The child's trunk lies 
on the operator's forearm. The head is delivered by trac- 
tion. The natural mechanism must be observed, keeping 
the long diameter of the head in the oblique diameter of the 
pelvis till past the brim. As the chin approaches the four- 
chette a finger introduced into the mouth depresses the 



PATHOLOGY OF LABOR. 



253 



.tongue for the admission of air. JSxpressio foetus by a 
skilled assistant is an important aid in bringing the head 
through the pelvis. (Fig. 58.) 



Fig. 38. 




The Smellie-Veit method of extracting the after-coming head. (Doderleix.) 



Wig and- Martin Method. Of manual manoeuvres this is 
the most efficient when the operator must work without 
assistance. The technique is as follows : Two fingers of 
one hand are placed in the child's mouth or pressed against 
the fossae caninae to control the mechanism, especially to 
maintain full flexion. With the other hand the head is 
driven through the pelvis by powerful suprapubic pressure. 
(Fig. 59.) 

Forceps. An assistant seizing the child's feet holds its 
body well up over the mother's abdomen. The forceps is 

12 



254 



ESSENTIALS OF OBSTETRICS. 



then applied to the head. This is the most reliable of all 
methods of extracting the after-coming head. Observing 
the normal mechanism and avoiding violence, the danger of 
maternal injuries is no greater than in manual extraction. 



Fig. 59. 




The Wigand-Martin method of delivering the after-coming head. (Dodeklein.) 



II. Dorso-posterior positions. On expulsion of the body 
rotate the occiput to the front by gentle torsion of the trunk 
and with the aid of external pressure applied over the 
mother's abdomen by an assistant. Then deliver as in pri- 
mary anterior positions. Kotation failing, deliver by trac- 
tion and suprapubic pressure, carrying the trunk downward 
and backward over the perineum. Should the chin catch 
over the brim of the pelvis, deliver, occiput first, by trac- 
tion upon the body directed upward and forward over the 
pubes, aided by suprapubic pressure or by the forceps. 



PATHOLOGY OF LABOR. 255 

Nuchal Arm. Should the forearm of the foetus be lodged 
behind the neck, rotate the body in the direction from the 
misplaced arm, guarding against too much torsion of the 
neck. The rotation of the head may, if necessary, be 
assisted by external pressure. Sometimes the nuchal arm 
may best be dislodged with the hand in the passages. 
Having disengaged the arm, proceed as in ordinary cases. 

In Failure of the Powers at or above the Brim one or 
both feet should be brought down, if this be possible without 
violence. 

With the aid of postural measures the breech may be 
dislodged from the brim after partial engagement. When 
the legs are extended, carrying the feet high up in the 
uterus, the foot may be brought down as follows : Passing 
two or three fingers into the uterus between the thighs, one 
thigh is pressed outward ; the knee is thus flexed and the 
foot brought down within reach of the operating hand. 

Impaction, or Failure of the Powers in the Cavity. Three 
methods are available for delivery, traction by finger, fillet, 
forceps. 

The finger hooked in the groin is competent when only a 
moderate amount of force is required. 

The fillet. A yard of strong muslin bandage or a soft 
handkerchief may be used as a fillet. It is oiled and knotted 
at one end. The knot is pushed up over the groin with one 
hand and hooked down on the opposite side of the thigh with 
the fingers of the other hand. Traction is then applied to 
the fillet with care to avoid doing violence to the structures 
of the groin by too great pressure. 

In dorso-posterior positions the fillet is made to encircle 
the pelvis, the free ends depending between the thighs. 
One end is passed over each groin from without inward and 
the loop slipped up over the sacrum. Or the fillet may be 



256 ESSENTIALS OF OBSTETRICS. 

passed over one groin and held in place with one hand 
while traction is made with the other. The latter precau- 
tion is necessary owing to the danger of fracturing the 
femur should the fillet slip and traction be made upon the 
central portion of the shaft. 

Forceps. In cases not manageable by the finger or the 
fillet forceps may be applied to the breech. One blade is 
placed over the sacrum and ilium, the other over the pos- 
terior surface of the opposite thigh, or the blades are ad- 
justed over the trochanters, avoiding pressure upon the ilia. 
Moderate traction is made and assisted with expressio foetus. 

The cephalotribe may be used to advantage if the foetus 
is dead. 

Transverse Presentation : Shoulder Presentation. 

A transverse presentation is one in which the long axis of 
the foetal ellipse lies across the long axis of the uterus. The 
presentation, however, is oblique rather than transverse. In a 
large proportion of cases cross presentations are spontaneously 
converted into longitudinal when labor begins. In persist- 
ent transverse presentation the shoulder, or sometimes the 
arm, becomes the presenting part after labor is established. 

Frequency. The frequency of shoulder presentations 
has been variously estimated, but may be fairly stated as 1 
in 250. 

Causes. The causes of cross-birth, which is a partial 
inversion of the foetal axis, are practically the same as those 
of breech-birth or complete inversion. This anomaly is 
therefore met with most frequently in unusual mobility of 
the foetus, twin pregnancy, foetal tumors, myomata of the 
lower uterine segment, undue pelvic inclination, pelvic de- 
formity, and low attachment of the placenta. 

Positions. Since the child's head may lie either to the 



PATHOLOGY OF LABOR. 257 

right or the left of the mother, and its back may be turned 
anteriorly or posteriorly, there are four possible positions in 
cross-births, as follows : 

Left scapulo-anterior — L. Sc. A. 
Right scapulo-anterior — R. Sc. A. 
Right scapulo-posterior — R. Sc. P. 
Left scapulo-posterior — L. Sc. P. 

It should be noted that these positions are named accord- 
ing to the direction of the presenting scapula. When the 
scapula looks to the left and front the position is a left 
scapulo-anterior, when to the right and front it is a right 
scapulo anterior position, and so on. 

Diagnosis. Abdominal signs: Absence of both foetal 
poles from the excavation after labor is established ; 

Presence of the head in one or the other iliac fossa. 

Vaginal signs : Glove-finger protrusion of the bag of 
waters ; 

Presenting part smaller, more yielding and less distinctly 
rounded than the hard globular head ; 

Especially significant is absence of any presenting part 
at the onset of labor ; 

After labor is well established the presenting part is a 
small, rounded prominence; it is distinguished from an 
ischial tuberosity by the absence of a companion ; from it 
run the humerus, the clavicle and the spine of the scapula 
in radiating lines ; 

The neck is felt on one side of the presenting part, the 
ribs on the other ; 

The axilla can be made out ; 

The elbow is identified by the olecranon. 

The position is determined by the location of the scapula 
to the right or left, anteriorly or posteriorly. The axilla and 
the elbow look toward the feet ; the thumb toward the head. 



258 ESSENTIALS OF OBSTETRICS. 

When an arm is prolapsed distinguish hand from foot, 
and the right from the left hand. Shake hands with the 
fetus; the right hand of the examiner fits the right hand 
of the foetus, and vice versa. 

Prognosis. In persistent transverse presentations one 
in ten of the mothers and half the children die. The risks 
to the mother are from pressure effects, exhaustion, sepsis, 
rupture of the uterus ; to the child, from pressure-effects, 
prolapsus funis. 

Spontaneous delivery. Very rarely spontaneous delivery 
takes place in one of the following methods : 

(a.) Spontaneous version. The shoulder presentation is 
converted into a breech or into a vertex birth by the uterine 
expulsive efforts. Such a change of presentation is com- 
mon at the beginning of labor. It occurs more frequently 
in multipara than in primiparse, oftener with a living than 
with a dead child. 

(b.) Spontaneous evolution. The mechanism of spontaneous 
evolution is as follows : As the child is driven down by the 
uterine contractions the head rides over the symphysis and 
the anterior shoulder becomes fixed under the pubic arch. 
The other shoulder is forced down over the posterior wall 
of the pelvis and is expelled first. It is then followed by 
the trunk. The head is born last. 

^Expulsion with trunk doubled on itself can occur when 
disproportion between the size of the pelvis and foetus favors. 
It is almost surely fatal to the child. 

Treatment. Before labor. Correct the malpresenta- 
tion by external cephalic version. To retain apply an 
abdominal binder and lateral compresses. 

During labor. Preserve the membranes ; evacuate the 
bladder and rectum ; note capacity of the pelvis, size of the 
child, situation of the retraction ring and the degree of 



PATHOLOGY OF LABOR. 259 

thinning of the lower uterine segment. Perform version, 
cephalic or podalic, by the bipolar or the internal method, 
under anaesthesia. Reduction of the malpresentation is 
often possible with the aid of the genu -pectoral or the Tren- 
delenburg position. In impacted and irreducible shoulder 
presentation decapitation will be required. Should the 
child be living and viable symphysiotomy may be con- 
sidered. 

Treatment of Complex Presentations. 

Head and Hand. When possible replace the hand ; 
this failing, deliver with forceps, placing the arm in the 
unoccupied side of the pelvis, or, better, perform podalic 
version. 

Hand and Foot or Head, Hand and Foot. Ex- 
tract by one or both feet. 

Nuchal Arm. The diagnosis is made by anaesthetizing 
the patient and introducing the hand into the passages. 

In vertex presentation the arm is dislodged with the 
hand in the uterus by rotating the body from the nuchal 
arm. Rarely version will be necessary. 

In head-last cases the nuchal arm is dislodged by seizing 
the delivered trunk with both hands and rotating the body 
from the misplaced arm. The other arm should first have 
been delivered. The reduction of the misplacement may 
be followed, if necessary, by introducing two fingers be- 
tween the shoulder and the symphysis and bringing down 
the arm in the manner practised in ordinary breech extrac- 
tion. 

In complex presentation, if the foetus is dead, delivery 
is best accomplished, as a rule, in the interest of the 
mother, by craniotomy. 



260 ESSENTIALS OF OBSTETRICS. 

ANOMALIES OF FCETAL DEVELOPMENT. 

Twins. 

Relative situations of twins are : one above the other, one 
beside the other or one in front of the other. 

Diagnosis, (a.) Abdominal signs : Excessive size and 
tension of the uterine tumor ; permanent tension of the 
tumor, with very limited mobility of the contents, should 
suggest twins ; 

Shape of the tumor; excessive width, a longitudinal sul- 
cus ; the latter, however, is not diagnostic ; 

Suprapubic oedema ; this is present also in simple hydram- 
nios ; 

Multiplicity of small parts ; 

Two dorsal planes ; 

Three or four foetal poles ; 

One head in the excavation and one in the upper uterine 
segment ; 

One head in the excavation and one in the iliac fossa ; 

Distance from the pelvic pole to the fundal pole over 
30.5 cm. (12 inches) ; 

Two foetal heart-sounds of different rates ; 

Two foetal heart-sounds of the same rate, but in widely 
different situations and on opposite sides of the abdomen ; 

Heart tones above the umbilicus and head in the exca- 
vation. 

(b.) Vaginal signs: A rapidly successive presentation 
of a head and a breech ; 

Four extremities offering at the brim ; 

Two amniotic bags presenting. 

Management op Labor in Twin Births. The man- 
agement of labor in twin births differs in nowise essen- 



PATHOLOGY OF LAB OB. 261 

tially from that of ordinary labor. The cord of the first 
child should be ligated on the placental as well as the foetal 
side, owing to the possible existence of a vascular com- 
munication between the two placenta?. Since the passages 
are dilated by the birth of the first child, the second birth 
is usually rapid, or, if necessary, may safely be made so. 
The delivery of the second child, however, should be left to 
nature except for cause. The foetal heart should be watched. 
As the over-distention of the uterus exposes the woman to 
post-partum hemorrhage, extra care will be needed to secure 
firm uterine retraction by manipulation and by the use of 
ergot. 

Interlocking Twins. 

This anomaly, which is exceedingly rare, presents two 
principal 

Varieties : (a.) Both presentations cephalic ; both heads 
offering, one impacted between the head and trunk of the 
other foetus. 

(6.) One presentation cephalic, one pelvic, the after- 
coming head of the breech birth being impacted between 
the head and trunk of the other foetus. 

Management. Disengage by a combined internal and 
external manipulation, with the aid of the knee-chest or 
the Trendelenburg position. The first child may be decapi- 
tated as a last resort. 

Double Monsters. 

Premature and spontaneous delivery is the rule. In 
most cases delivery will be facilitated by podalic version if 
the diagnosis is made in time to operate early in the labor. 
Resort should be had to embryotomy in difficult cases. 

12* 



262 ESSENTIALS OF OBSTETRICS. 

Hydrocephalus. 

Hydrocephalus is attended with a serous effusion into the 
cranial cavity with consequent enlargement of the cranial 
vault. The effusion is usually found in the ventricles, very 
rarely in the arachnoid or subarachnoid cavity. 

The quantity of fluid may be several pints. Spina bifida 
or other anomalies of development generally coexist. The 
etiology is obscure. Syphilis and alcoholism are among 
the causes assigned. 

Diagnosis, (a.) Head-first eases. 

Abdominal signs : The best diagnostic evidence is afforded 
by measurement of the head as determined with a pelvim- 
eter through the abdominal walls or estimated by palpation. 
Mensuration of the head by this means may be impos- 
sible owing to hydramnios. 

Vaginal signs: Size, elasticity and fluctuation of the 
cranial vault ; excessive width of the sutures ; the latter, 
however, is not peculiar to hydrocephalus ; 

Large fontanelles ; 

Sometimes a supplementary fontanelle between the an- 
terior and the posterior ; 

Unnatural prominence of the frontal and parietal bones. 

The size of the head cannot be estimated by the usual 
method of vaginal examination, which explores only the 
presenting part. Elasticity and fluctuation are not always 
readily detected when the cranial vault is rendered tense by 
firm engagement in the pelvic brim. When in doubt the 
patient should be placed under an anaesthetic and the hand 
introduced into the uterus. 

(b.) Head-last cases. In one case in three the hydro- 
cephalic foetus presents by the breech. The signs of hydro- 
cephalus in breech birth are : 



PATHOLOGY OF LABOR. 263 

Body wasted ; 

Head arrested after the birth of the trunk ; 

The size of the head as determined by measurement or 
by palpation through abdominal wall. 

Prognosis. Child. The mortality is over 80 per cent. ; 
even if the child is born alive it is of feeble viability ; nearly 
all die soon after birth. 

Mother. The mortality is estimated at 18 per cent., 
from exhaustion, rupture of the uterus, hemorrhage. 

Treatment. The delivery may be left to nature or may 
be effected by version or perforation, according to the degree 
of obstruction. Version, however, is seldom available, owing 
to danger of uterine rupture. Aspiration of the cavity with 
a small trocar passed through a fontanelle or suture may 
often be substituted with advantage for craniotomy. The 
life of the child is not necessarily lost by drawing off the 
fluid. The forceps is not applicable; the grasp is insecure. 
When the head has been perforated the cephalotribe is the 
most efficient tractor. 

In difficult head-last cases the head may be perforated or 
the spinal canal opened and the cranial cavity catheterized 
through it. The perforator can be passed safely beneath 
the skin, entering it over the neck. 

Serous effusions into other cavities, if they cause marked 
dystocia, are to be evacuated by aspiration of the dropsical 
cavities or by free incision. 

Tumors. 

Hygroma, fibroma, lymphangioma, myoma, sacrococcy- 
geal teratoma, spina bifida, enlargement of abdominal vis- 
cera and other tumors are occasionally met with. 

Treatment. Delivery of the foetus intact being impossi- 



264 ESSENTIALS OF OBSTETRICS. 

ble, fluid tumors may be reduced by tapping or by incision ; 
solid, by segmentation. 

ANOMALIES OF LABOR ARISING FROM ACCIDENTS 
OR DISEASE. 

Prolapsus Funis. 
In prolapsus funis a loop of the navel cord slips down in 
advance of the presenting part of the foetus. As the labor 
goes on the misplaced portion of the cord is compressed 
between the part presenting and the walls of the birth canal, 
and without relief the foetus dies usually within five minutes 
from the interruption of the foe to -pi a cental circulation. 

Frequency. Prolapse of the cord occurs once in about 
two hundred and fifty labors. 

Causes. Anything which prevents the presenting part 
from completely and continuously filling the lower uterine 
segment predisposes to prolapsus funis, e. g. : 
Hydramnios ; 
Deformed pelvis ; 

Malpresentation (frequency in head presentation. 1 
in 304 ; face, 1 in 32 ; pelvic, 1 in 21 ; shoulder, 
1 in 12) ; 
Complex presentations ; 
Twins ; 
Small foetus ; 
Multiparity ; 
Pendulous abdomen ; 
Uterine myomata ; 
Low placental insertion ; 
Rupture of the membranes while the woman is 

standing. 
Marginal insertion of the cord, or 
Excessive length of the cord may favor prolapse. 



PATHOLOGY OF LABOR. 265 

Diagnosis. The prolapsed cord may be found in the 
bag of waters, in the vagina, or protruding through the 
vulva. Before rupture of the membranes distinguish from 
fingers and toes by the anatomical characters of the latter. 
The fcetal parts will usually be drawn up out of the way 
when touched. After rupture of the membranes the diag- 
nosis presents no difficulty. 

Prolapse of the cord must be distinguished from protru- 
sion of a loop of intestine following rupture of the uterus. 
In the latter there is more or less hemorrhage, the prolapsed 
loop is larger, the mesentery can be felt, and pulsation is 
absent. The prolapsed part of the cord should be ex- 
amined for the funic pulse to learn whether the child is 
living. Absence of pulsation for fifteen minutes may be 
taken as evidence of the death of the foetus. Listen for the 
fcetal heart over the abdomen. 

Prognosis. The prolapse itself entails no additional 
risk to the mother ; the conditions which give rise to it and 
operative measures necessitated by it may do so. 

The fcetal mortality may be stated at 50 per cent. It is 
highest in vertex presentations and in first labors. The 
danger is much increased after the membranes rupture. 

Treatment. Before rupture of the membranes. Of 
first importance is the preservation of the membranes if still 
unbroken. It should be a rule to rupture them in no case 
intentionally without first examining for possible prolapse 
of the cord. Keep the patient in the lateral or latero-prone 
position. Place her on the side opposite that on which the 
cord came down in the hope that the displaced loop may 
return by its own weight. Push the cord up between the 
pains, with care to avoid rupturing the membranes. Crowd 
the presenting part down and guard against recurrence of 
the displacement till the presenting part has firmly engaged. 



266 ESSENTIALS OF OBSTETRICS. 

Listen at short intervals over the abdomen for the foetal 
heart. 

After rupture of the membranes. Reposit at once if the 
funic pulse can be felt ; if the pulsation has ceased, but the 
heart-tones are still audible, push up the presenting pole 
and replace the cord after pulsation returns. 

Methods, (a.) Manual reposition. Place the patient in 
the latero-prone or the genu-pectoral or the Trendelenburg 
posture. Anaesthesia is generally necessary. Twist the pro- 
lapsed loop loosely into a rope and push it up anteriorly, 
operating between the pains. Much handling of the cord is 
dangerous to the child ; it enfeebles the foetal heart. To re- 
tain, crowd the presenting pole firmly into the excavation 
and hold it there by manual pressure or with an abdominal 
binder. Let the patient lie in the latero-prone position, 
with the hips elevated, or in the Trendelenburg position. 
Examine through the vagina from time to time, lest the 
cord slip down again as the labor progresses. 

Listen frequently for the strength and rate of the foetal 
pulse. Do not subject the mother to the discomfort and 
the risks of reposition till assured that the child is not dead 
or non-viable. 

(b.) Instrumental reposition. The aid of posture is 
essential, as in the manual method. An instrumental re- 
positor is substituted for the hand. An English catheter, 
with a tape attached and loosely looped over the cord, makes 
an easily improvised and efficient repositor. After complete 
reposition the catheter may be left in the uterus. The in- 
strument is armed with a stylet, which is withdrawn after 
replacing the cord. Measures for retention are to be used 
as in the manual method. 

(c.) Forceps or breech extraction. Should all attempts 
at reduction and retention fail, the child may sometimes be 



PATHOLOGY OF LABOR. 



267 



saved by rapid delivery. This is possible in vertex presen- 
tation with forceps or by version ; in breech cases, by the 
usual technique of breech extraction. The cord, meanwhile, 
should be disposed where it will receive the least pressure, 
opposite the sacroiliac joint in that side of the pelvis in 
which there is most room. It is sometimes best to resort to 
version primarily. 

Inversion of the Uterus. 

The inversion may be complete or partial. It begins 
usually as a cup-shaped depression at the fundus. (Fig. 60.) 
In the vast majority of cases it occurs just before, rarely 
directly after, the expulsion of the placenta. 




Three stages of inversion : 1. Cup-shaped depression of fundus. 2. Partial 
inversion. 3. Complete inversion, a, fundus uteri ; b b, cavity ; c, vagina ; d d, 
mouth of inverted portion. 



Frequency. The frequency of puerperal inversion of 
the uterus may be roughly estimated at 1 : 100,000 to 
1 : 150,000. In properly conducted labors the accident is 
well-nigh impossible. 

Etiology. Relaxation of the uterus in the third stage 
of labor is the primary cause. Unskilled pressure on the 



268 ESSENTIALS OF OBSTETRICS. 

fundus, traction on the cord while the uterus is relaxed, or 
a fundal placental seat may contribute to the accident. 

Diagnosis. Symptoms. Complete inversion of the uterus 
is followed by shock, pain, hemorrhage and generally by 
vesical and rectal tenesmus. Exceptionally both the hem- 
orrhage and the pain may be insignificant. 

Physical examination. The bladder and the rectum 
should be empty. In partial inversion of the uterus a cup- 
like depression can be felt at the fundus by abdominal 
touch. Complete inversion is recognized by the absence of 
the usual abdominal tumor as made out by palpation or 
by combined abdomino-vaginal or abdomino-rectal examina- 
tion, by the presence of a vaginal tumor and by the char- 
acter of the tumor. 

The inverted uterus is distinguished from a pedunculated 
fibroid by its special contractility, by its large pedicle and 
by greater pain and greater immobility on attempting tor- 
sion. In case of a polypus depending through the cervix 
a sound may be passed alongside the tumor into the uterine 
cavity, yet differentiation is sometimes difficult. It should 
be remembered that the placenta may still be adherent. 

Prognosis. Without prompt reposition the prognosis 
is extremely grave. The mortality, even in skilled hands, 
is one-fifth to one-third, from hemorrhage, shock, peri- 
tonitis, gangrene of the uterus, septicaemia. 

Treatment. The preventive treatment depends on the 
proper management of the placental stage of labor. Stimu- 
late prompt and persistent retraction, meantime holding the 
anterior firmly against the posterior wall of the uterus by 
pressure over the abdomen. 
Methods of Reposition ; 

(a.) Simple cases. Immediately after inversion reduction 
is seldom difficult. The patient having been anaesthetized, 



PATHOLOGY OF LAB OB. 269 

the operator places one hand on the abdomen over the in- 
verted uterus for counter-pressure, using the fingers at the 
same time for dilatation of the cervical ring ; he cones the 
fingers of the other hand, and, passing them into the vagina, 
applies the finger-tips to the fundus. Sometimes the press- 
ure is best made over the insertion of one Fallopian tube ; 
sometimes over the central portion of the fundus. The 
fundus once fairly indented complete reduction is easily 
effected. The force must be directed to one side of the 
sacral promontory. When the placenta is adherent replace 
all ; when it is partially detached separate and remove it 
before trying taxis. 

(b.) Difficult cases. Taxis may be tried with the aid of 
posture. This failing, recourse may be had to elastic press- 
ure applied with a water-bag, alternated with taxis. Leave 
the bag in place for about eight hours, then remove it and 
repeat the taxis. Failing, apply the water-bag again for 
another eight hours. Rigorous precautions must be ob- 
served to prevent infection. Extreme measures are inad- 
visable during the puerperium, and attempts at reposition 
should be deferred for several weeks if not successful within 
twenty-four hours. 

RUPTURE OF THE UTERUS. 

Nature of the Accident. Usually the tear begins in 
the lower segment. It may take any direction and reach 
any extent within the limits of the organ. The vagina or 
the bladder may be involved. The portio vaginalis is some- 
times torn off. Fissures of the cervix of greater or less 
depth occur in most labors. The rupture is said to be com- 
plete when it extends from the uterine into the peritoneal 
cavity ; otherwise it is incomplete. Incomplete rupture not 



270 



ESSENTIALS OF OBSTETRICS. 



infrequently takes place into a broad ligament. Sponta- 
neous rupture occurs very seldom during pregnancy, most 
frequently toward the end of the first stage of labor. (Fig. 
61.) 

Fig. 61. 




Rupture of the Uterus. (Schaeffer.) 
PL Placental site. BR. Retraction ring. Eu. Seat of rupture. Vag. Vagina. 



Frequency. This accident occurs in 1 in about 4000 
labors. It is less frequent in first than in subsequent labors. 

Etiology, (a.) Predisposing causes : Local lesions of 
the uterine muscle ; examples are carcinoma, myoma or the 
cicatrix of an old laceration or of Cesarean section not 
properly sutured. Pressure between the head and a sharp 
bony prominence, as the sacral promontory or an exostosis, 
may contribute to the accident. The chief predisposing 



PATHOLOGY OF LABOR. 271 

cause is obstructed labor, with excessive thinning of the 
lower uterine segment. 

(b.) Exciting causes : Abuse of ergot and operative vio- 
lence, such as forceps in an undilated os, version in a firmly 
contracted uterus, are prominent exciting causes. 
Diagnosis. Danger signals are : 

Evidence of obstruction with violent uterine con- 
tractions ; 
Tenseness of the round ligaments ; 
Excessive retraction of the uterus as shown by high 
position of the retraction ring, more than half-way 
to the umbilicus ; 
Preternatural pain and restlessness ; 
Abdomen over-sensitive to pressure. 
Signs of rupture : 

Sense of tearing ; 

Abrupt cessation of labor pains, in complete rup- 
ture ; 
Persistent uterine pain ; 

Hemorrhage — external, retroperitoneal, intraperito- 
neal ; 
Collapse — in proportion to the amount of blood-loss ; 
Presenting part absent or receding ; 
No evidence of foetal life ; 
Knuckle of intestine in the uterus ; 
Uterus and the child forming separate tumors. 
The diagnosis is confirmed on examining with the fingers 
in the uterus. 

Prognosis. In complete rupture the mortality for the 
mothers is 90 to 95 per cent., from hemorrhage, peritonitis, 
septicaemia. The foetal mortality is even greater from com- 
plete interruption of the utero-placental circulation. 

Treatment. 1. Preventive. The cause of obstruction 



272 ESSENTIALS OF OBSTETRICS. 

should be removed if possible ; malpositions should be cor- 
rected. In excessive retraction of the uterus immediate 
delivery is indicated, as a rule, even though it necessitate 
embryotomy. 

2. Curative. Incomplete rupture. If the injury is con- 
fined to the upper uterine segment, the child and placenta 
being delivered, the treatment should be expectant. Hemor- 
rhage is controlled by firm uterine contraction. Subperito- 
neal laceration of the cervix and lower uterine segment is 
attended with the formation of a more or less extensive 
hematoma. The blood-clot should be removed and the 
wound-cavity packed with iodoform gauze. Persistent arte- 
rial hemorrhage must be controlled by haemostatic suture. 
Mere oozing is arrested by the packing. The gauze is to be 
removed in two or three days and the wound-cavity kept 
clean by douching. 

Complete rupture, (a.) Drainage. When the foetus or 
the larger part of it is still in the uterus it should immedi- 
ately be extracted by the natural passages. In vertex pres- 
entation delivery is best effected by perforation in the grasp 
of the cephalotribe or forceps. The placenta must be 
promptly removed. Should it have escaped into the peri- 
toneum it may sometimes be drawn down to the uterine wound 
by the cord and extracted manually. Prolapsed intestines 
must be reposited. Drainage is then to be established as fol- 
lows : A large rubber tube is folded, the limbs of the tube tied 
together, the bight of the tube perforated in several places 
and passed through the uterine rent and about an inch 
beyond ; or a drain of aseptic wicking or gauze may be 
substituted for the tube. The uterus must be made to 
contract. The drain is removed in two or three days on 
cessation of much discharge. 

(b.) Coeliotoiny should be done when the foetus is wholly 



PATHOLOGY OF LABOR. 273 

in the peritoneal cavity, has been long dead, when there 
has been much hemorrhage into the peritoneum, when the 
cervix is not dilatable, or the site of rupture not favorable 
for drainage. The peritoneum is cleansed by irrigation 
with the normal salt solution. The uterine lacerations are 
closed by deep suture. 

Amputation of the uterus should be resorted to when 
necessary to avert sepsis ; especially is this advisable if the 
lacerations are extensive or the uterus is infected. 

Treatment of Ancemia. If there is much loss of blood 
the anaemia is to be treated as in other cases, by bandaging 
the extremities, raising the foot of the bed, by hypodermic 
or intravenous and by rectal injections of the saline solu- 
tion, by the administration of opium, strychnine and by 
other restorative measures. (See p. 278.) 

THE HEMORRHAGES. 
Ante-partum Hemorrhage. 

1. Placenta Praevia. 

Definition. The placenta is said to be praevia when its 
site encroaches upon the zone of the uterus which undergoes 
dilatation in the first stage of labor. 

Degrees of placenta previa. 1. Partial — partially cover- 
ing the zone of dilatation. 

2. Complete — wholly covering the zone of dilatation ; 
full central implantation is rare. 

Frequency. Placenta praevia is met with in about one 
in one thousand labors. It occurs more frequently in multi- 
para than in primiparae. 

Causes. Causes of misplaced placenta are conditions 
giving rise to tardy fixation of the ovum, permitting it to 



274 ESSENTIALS OF OBSTETRICS. 

drop into the lower uterine segment ; e. g., endometritis, 
enlargement of the uterus, relaxation of the uterus. 

The cause of hemorrhage during the labor is the separa- 
tion of the lower margin of the placenta, which takes place 
as soon as canalization of the cervix begins. Hemorrhage 
before labor begins is explained by partial detachment of 
the misplaced placenta occurring from accidental causes. 

The source of the bleeding is the uterus, and to a limited 
extent the placenta as well. 

Symptoms. Usually there are none in the early months. 
The first warning is a sudden outpour of blood of greater or 
less amount. The first hemorrhage is most frequently ob- 
served in the seventh or eighth month, rarely not till the 
onset of labor. Hemorrhage during pregnancy always de- 
mands immediate investigation to determine the source of 
the bleeding. This is doubly imperative in the later months. 
In distinguishing from other hemorrhages it should be re- 
membered that bleeding during labor in placenta prsevia is 
most profuse in the intervals between the pains. 

Physical Signs, (a.) Abdominal. 1. The location of 
the placenta may sometimes be made out by abdominal 
palpation. Beneath the placenta the fetal parts are obscure 
to the touch, elsewhere they are more distinctly felt. In 
most instances of anterior implantation the convex edge of 
the placenta can be traced as a resisting ring. 

2. Mapping out the round ligaments by abdominal pal- 
pation, if they are found to run downward and inward over 
the anterior surface of the uterine tumor, it may be assumed 
that the placental implantation is upon the posterior wall of 
the uterus ; if they run along the lateral margins of the 
uterus, the placental seat is on the anterior wall. When 
they are found in neither of these positions a prsevial inser- 
tion is to be suspected. 



PATHOLOGY OF LAB OB. 275 

(b.) Vaginal Unusual development of the cervix, 
especially when the placenta praevia is complete : 

Bosginess of the cervix and lower segment of the uterus ; 

A cushiony mass between the presenting part of the foetus 
and the examining finger. 

The characteristic stringy feel of the detached surface of 
the placenta on examination through the cervical canal : 
distinguish from blood-clots which are more friable. 

In marginal placenta praevia the edge may be felt if 
detached. 

Prognosis. The maternal mortality in cases that go to 
the later weeks of pregnancy is one-fifth to one-fourth, in- 
cluding deaths from the sequela?. Two-thirds of the chil- 
dren are lost. 

The mortality for both mother and child must obviously 
vary, however, with the degree of placenta praevia. The 
maternal mortality results from hemorrhage, shock, sepsis, 
and thrombotic affections ; the foetal from asphyxia, the 
effect of the maternal hemorrhage on its blood-supply, pre- 
maturity and operative causes. Maternal deaths from 
placenta praevia are extremely rare before the seventh 
month. The danger to life increases as gestation advances 
by reason of the increasing size of the bloodvessels and the 
progressive loosening of the placental attachment. 

Treatment, (a.) Before viability. In general the 
treatment should be expectant. Partial or complete rest 
must be enjoined according to the amount of bleeding, and 
a general regimen prescribed very similar to that pursued 
for the arrest of threatened abortion or premature labor. 
If the hemorrhage is copious, the placenta praevia complete, 
or the foetus dead, the uterus should be emptied. 

(b.) After viability. Induction of labor is indicated im- 
mediately the diagnosis is made, simple cases excepted. 



276 ESSENTIALS OF OBSTETRICS. 

Management of Labor. The principal indication in the 
management of labor with placenta prsevia is the control of 
hemorrhage. Hemorrhage controlled, wait, but remain 
with the patient until delivered. 

Nature is equal to the control of the bleeding in rare 
cases of partial placenta prsevia by extra-rapid delivery. 
Rupture of the membranes and the application of a firm 
abdominal binder may suffice in mere marginal placenta 
praevia with but little hemorrhage. The presenting pole 
acts as a tampon. 

Forceps. If the cervix is sufficiently dilated forceps, with 
very moderate traction, may be tried in similar conditions, 
if required to hold the head in the lower uterine segment 
as a tampon. 

The vaginal tamponade is especially valuable when there 
is little or no dilatation of the cervix. It is a competent 
measure as the chief reliance in the treatment of placenta 
prsevia in general. The best material is sterilized gauze in 
strips ; it may be used plain or impregnated with a non- 
toxic antiseptic such as oxide of zinc. To pack securely 
it must be wet. The vagina, if healthy, requires no anti- 
septic cleansing before placing the tamponade. The dress- 
ing is removed in six or eight hours. It may be renewed 
if the dilatation is not sufficient for delivery or resort be 
had at once to bipolar version. 

Water-bags. A most efficient means of controlling the 
hemorrhage is the dilating water-bag in the cervix, Barnes', 
McLean's, or the Champetier de Ribes. The latter, how- 
ever, though most efficient mechanically is difficult to 
render aseptic. 

Podalic version is a measure of the greatest value for con- 
trolling the hemorrhage. It is especially indicated in case 
of much bleeding with little dilatation and before rupture 



PATHOLOGY OF LABOR. 277 

of the membranes. With one or both feet down the foetus 
serves as a conical cervical plug. Bipolar version has the 
great advantage that it can be done as soon as one or two 
fingers can be passed through the cervix. The edge of 
the placenta is pushed aside and the fingers passed through 
the membranes. Even after sufficient dilatation it is seldom 
necessary to pass the entire hand into the uterus. After 
version the child may be extracted when the dilatation is 
complete. The delivery must be effected very slowly and 
with extreme care to avoid shock. As a rule it is better, if 
possible, to leave the expulsion to nature. 

Manual dilatation and immediate extraction of the child, 
as recently advocated by eminent authority, must be re- 
garded as a questionable procedure for general adoption 
and doublv so when the woman is exsanguinated or much 
exhausted. 

Other Methods. Separation of the placenta from the lower 
uterine segment (Barnes) permits retraction of the part 
thus uncovered. The area of detachment should be not 
less than 11.5 cm. (4 \ inches) in diameter. 

This procedure is not to be recommended except in 
simple cases of partial placenta pnevia. 

Complete separation and extraction of the placenta are 
applicable in case the child is dead or not yet viable. 
(Simpson.) 

Extraction of the child by perforation of the placenta in 
central or nearly central implantation is permissible. 

Precautions. Avoid too precipitate and violent interfer- 
ence, especially if there has been much hemorrhage. It is 
largely responsible for the high death-rate of placenta praevia. 

Guard especially against shock, infection and post- 
partum hemorrhage. Ergot should be given for several 
days after labor. 

13 



278 ESSENTIALS OF OBSTETRICS. 

Treatment of Acute Anemia. Treatment is often 
required after the delivery to combat the effects of excessive 
blood-loss. The principal measures are : Elevation of the 
hips, bandaging the extremities — auto-transfusion — con- 
tinued for a few hours, hot applications to the feet ; opium, 
gr. ij p. r. n., or its equivalent; hypodermic injections of 
whiskey, fluid extract of digitalis, njj to n^v, strychnine, 
gr. fa ; trinitrin, gr. fa to -fa repeated p. r. n. The in- 
jection of the normal salt solution (fa of 1 per cent, ap- 
proximately gr. iij ad §j) into the rectum, into the cellular 
tissue between the scapulas, or into a vein, is a most valu- 
able measure. A readily improvised apparatus for intra- 
venous infusion is made with a glass funnel, a few feet of 
rubber tubing and a canula of glass or metal. Apparatus 
and solution should be sterilized by boiling, and the latter be 
filtered. The salt solution should be slowly injected at the 
temperature of 100° F. Two or three pints may be used. 

The large bowel is kept filled with the physiological 
saline solution, with plain warm water, or with suitable 
nutrient enemata. 

For the thirst a saline drink — e.g., a weak solution of am- 
monium acetate — is recommended. Liquids by the stomach 
must be given in small quantities and often, beginning with 
5J, at intervals of a minute or two. Plain hot water, 
brandy or whiskey and hot Water are good restoratives. 
The use of nutrient fluids may be begun after a few hours. 

2. Accidental Hemorrhage. 

This term applies to bleeding resulting from the partial 
separation of a normally seated placenta when it occurs in 
the later months of pregnancy. 

Varieties, (a.) Apparent, in which the blood is dis- 
charged by the vagina. 



PATHOLOGY OF LABOR. 279 

(6.) Concealed, in which the effused blood collects in the 
uterine cavity. Either of the following conditions may 
obtain : 

1. Placenta detached at the centre, the margin adherent ; 

2. Placenta detached at one edge, partially lifting the 
membranes beyond the margin ; 

3. Same as in 2, but overlying membranes ruptured 
and blood escaping into the amniotic sac ; 

4. Separation of one edge of the placenta and of the 
adjacent membranes, but the lower segment of the uterus 
occluded by the foetal head. 

Causes : The loose attachment of the placenta, normal 
to the last weeks of pregnancy ; 
Violent muscular effort ; 
Violent uterine contractions ; 
External violence, as blows or falls ; 
Nephritis ; 

Acute infectious diseases ; 
Placental disease. 

Diagnosis. Apparent variety. It is necessary to dis- 
tinguish from rupture of the uterus and from placenta 
prsevia. The former occurs later in labor and is attended 
with recession of the presenting part, with diminution of 
the uterine tumor and the development of a new abdominal 
tumor. The latter is readily recognized or excluded by a 
physical examination. 

Concealed variety. The principal signs are : 
Persistent tension of the uterus ; 
A node or boss on the uterine surface at the site of 

the retro-placental blood collection ; 
Atony of the uterus ; 
Uterine tumor boggv ; 
Foetal parts obscured to palpation ; 



280 ESSENTIALS OF OBSTETRICS. 

Continuous pain in certain cases from distention of 

the perimetrium ; 
Bloody liquor amnii — detected by pushing up the 
presenting part and allowing a portion of the liquor 
amnii to escape ; 
Foetal heart-tones feeble and irregular. 
Signs of internal hemorrhage, viz., collapse, pallor, sur- 
face cold, clammy, especially the extremities, excessive 
perspiration, respiration irregular, sighing, sobbing, yawn- 
ing, pulse rapid, thready, compressible, thirst, jactitation, 
tinnitus aurium, dyspnoea, nausea, dimness of vision, syn- 
cope. It should be remembered that concealed may coexist 
with an insignificant apparent hemorrhage. 

Prognosis. Apparent variety. In this form the prog- 
nosis is not usually grave for the mother, but is frequently 
fatal to the child. 

Concealed variety. For the mothers the mortality is 50 
per cent, from shock due to hyperdistention of the uterus 
and operative causes, from blood-loss before and during 
labor, from post-partum hemorrhage and the sequelae ; the 
foetal death-rate is 90 per cent, or more. 

Treatment. In either variety the cervix should be 
dilated manually and the membranes be ruptured. Firm 
compression of the uterus is maintained by means of a 
binder, or by manual support applied by a skilled assistant, 
and ergot is given hypodermically. After full dilatation 
the delivery is rapidly completed by forceps or version, or 
in dead or non-viable foetus by embryotomy. Precautions 
should be taken against post-partum hemorrhage. 

Post-partum Hemorrhage. 

Definition. By post-partum hemorrhage is meant hem- 
orrhage occurring shortly after the birth of the child and 



PATHOLOGY OF LABOR. 281 

having its origin at the placental site. The accident can 
seldom happen in well-managed labors. Bleeding from lacer- 
ations of the passages does not come within the meaning of 
this term in its technical sense. To distinguish excessive 
from the physiological flow it is necessary to remember that 
normally; the blood-loss at the birth of the child varies from 
two or three ounces to a pint. 

Causes. Causes are imperfect ligation of the uterine 
vessels in consequence of inertia uteri from exhaustion, 
overdistention of the uterus, badly managed third stage, 
excessive use of chloroform, full bladder, rectum packed 
with feces. The retention of blood coagula or of fragments 
of secundines tends to prevent full uterine retraction and 
closure of the vessels. Uterine neoplasms may have a like 
effect. 

Diagnosis. Danger signals : A history of hemorrhage 
in previous labors ; pulse over-rapid, above 100 ; imperfect 
retraction detected by palpation over the abdomen; presence 
of other recognized causes of hemorrhage. 

Signs: A sudden outpour of blood; no uterine globe; 
systemic effects of acute hemorrhage. (See page 280.) 

It must not be forgotten that the absence of external bleed- 
ing does not, alone, forbid the diagnosis of hemorrhage. 
Excessive bloody flow with firm uterine contraction does 
not proceed from the uterine cavity ; it comes from lacera- 
tions of the cervix, vagina or vulva. 

Treatment. Prophylaxis. The preventive treatment 
must be addressed to the uterine retraction. The uterus 
should be watched, with the hand continuously on the ab- 
domen, from the birth of the child and for at least a half- 
hour after the placenta is delivered. Friction may be used 
if required to provoke normal contractions. Fluid extract 
of ergot, 5ss, hypodermically, and repeated hourly, p. r. n., 



282 ESSENTIALS OF OBSTETRICS. 

is a valuable prophylactic. It is especially indicated after 
chloroform anesthesia and in all conditions which pre- 
dispose to hemorrhage. It is a wise precaution to give 
ergot on birth of the head when there is reason to fear 
post-partum hemorrhage. It is the abuse, not the proper 
use, of ergot that has brought it into disrepute in certain 
quarters. 

Remedial Measures, (a) Moderate hemorrhage. Manip- 
ulation of the uterus, with one or both hands over the 
abdomen ; conjoined manipulation with one hand over the 
abdomen and two or three fingers of the other hand in the 
posterior vaginal fornix forcibly anteflexing and compress- 
ing the uterus ; fluid extract of ergot, 3ss, subcutaneously ; 
hot intra-uterine douche, two or three gallons, at a tempera- 
ture of 115° to 120° F. 

(b.) Severe hemorrhage. Compression and kneading of 
the uterus, with one hand in the cavity and the other on 
the abdomen ; hot intra-uterine injections at a temperature 
between 120° and 125° F. ; hand in the cavity of the 
uterus, raking the walls vigorously with the finger-tips. 

The Uterine Tamponade. A most efficient measure for 
the control of severe post-partum hemorrhage is the uterine 
tamponade with iodoform gauze or plain sterilized gauze in 
strips about two inches wide. . It should be reserved, how- 
ever, as a last resort. 

Method. Place the patient in the lithotomy or the Sims 
position, catch the cervix with a volsella and draw it well 
down. Carry the gauze into the cavity of the uterus with 
a uterine dressing-forceps over the palmar surface of one 
hand as a guide. Lacking instruments the packing may 
be placed with the fingers alone. Remove cautiously within 
twenty-four hours. 

Additional measures are the following : Application of 



PATHOLOGY OF LABOR. 283 

the child to the breast as a reflex excito-motor ; compression 
of the aorta, quite useful as a temporary expedient ; com- 
pression of the uterus, with the fingers of one hand in the 
vagina against the cervix and the other hand on the abdo- 
men ; flagellation to the lower abdomen with a wet towel ; 
faradism of the uterus, one electrode within the uterus and 
one over the abdomen or the upper sacral region, or both 
electrodes over the abdomen, one on either side of the uterus; 
curettage ; swabbing the cavity with tincture of iodine. 

Hemorrhage from a lacerated cervix is best controlled by 
suture. The first stitch should be passed just above the 
angle of the tear. Vaginal hemorrhage should be arrested 
by suture. Anaemia is treated as in other cases. 

Secondary Post-partum Hemorrhage. 

Definition. By secondary post-partum hemorrhage is 
understood hemorrhage from the placental site occurring 
within the post-partum month later than six hours after labor. 

Causes. The usual causes are retention of membranes, 
placental fragments or blood-clots, congestion of the uterus 
from misplacement or other causes, getting up too soon, 
violent emotion. 

Treatment. Keep the patient in bed and remove the 
causes if possible; correct uterine displacements. Hot 
vaginal douches, two or three gallons at a temperature of 
115° to 120° F., are effective. These measures failing, 
curette the uterine cavity and pack with iodoform gauze ; 
remove the packing in twelve to twenty-four hours. 

SEPARATION OF THE SYMPHYSIS PUBIS. 

Rarely rupture of the pubic symphysis may occur spon- 
taneously, owing to the excessive relaxation of the joint 



284 ESSENTIALS OF OBSTETRICS. 

which sometimes develops in the later months of pregnancy. 
It is more frequently the result of unskilful use of forceps. 
The vagina and bladder are sometimes lacerated. Tears of 
the anterior soft parts may extend into the peritoneum. 

Diagnostic Signs. Mobility of the pubic bones upon 
each other ; a sulcus between the bones ; locomotion im- 
peded on getting up. The mobility of the bones is readily 
made out by forcibly flexing and extending the thighs and 
by rotating one knee outward, patient on the back. 

Treatment. Keeping the patient in bed with the use 
of a firm pelvic bandage maintained for four weeks, if 
begun directly after labor, can generally be trusted to bring 
about union of the bones. Neglected cases may be treated 
by vivifying the joint-surfaces subcutaneously and applying 
the bandage for four weeks, the patient maintaining a re- 
cumbent position. Suturing the bones with silkworm-gut, 
catgut or silver wire is seldom advisable. 

ECLAMPSIA. 

Definition. Puerperal eclampsia is synonymous with 
puerperal convulsions. The convulsions are epileptiform 
in character, and are usually associated with albuminuria. 
They occur most frequently toward the close of pregnancy, 
during the labor, or in the first few days of the puerperium. 
Convulsions in childbed from hysteria, epilepsy or cerebral 
lesions are not included under this term. It refers only to 
convulsions resulting from pregnancy. 

Frequency. The frequency is variously estimated at 1 
in from 250 to 500 cases of advanced gestation. It occurs 
in about 1 in 4 of all cases of pregnancy nephritis. The 
disease, however, appears to be more prevalent at certain 
times and in certain localities. Nephritis, which is gener- 



PATHOLOGY OF LABOR. 285 

ally associated with eclampsia, is found in 6 per cent, of 
gravid women that go to term. Eclampsia is most frequent 
in primiparse, and ten times more so in multiple than in 
single pregnancies. 

Etiology, The principal cause of the convulsions is a 
toxaemia with imperfect elimination by the kidneys and 
other emunctories. The precise nature of the poison is not 
yet known, but it is believed to be complex, probably of 
urinary, biliary, and foetal origin. Exceptionally the renal 
lesion is nothing more than acute insufficiency, usually it is 
an acute parenchymatous nephritis. Sometimes the acute 
is engrafted upon a chronic nephritis. The cause of the 
nephritis and other factors in the toxaemia is obscure. Reflex 
irritation from the uterus is a potent co-operating cause of 
eclampsia. 

Premonitory Symptoms and Signs : 

Scantiness of urine ; 

(Edema, especially of the face ; 

Lassitude ; 

Headache, generally frontal, suboccipital rarely ; 

Nausea and other digestive derangements ; 

Contracted pupils ; 

Visual disturbances ; 

Epigastric pain ; 

Albuminuria ; 

Deficiency of urea and of other urinary solids ; 

Tube-casts in the urine. 
Differential Diagnosis. Puerperal eclampsia is gen- 
erally to be distinguished from hysteria and epileptic con- 
vulsions by the urinary examination and by the history. 

Clinical Phenomena. The attack is usually ushered 
in by the symptoms already referred to. At the onset of 
the convulsive paroxsym the eyes become fixed, apparently 

13* 



286 ESSENTIALS OF OBSTETRICS. 

upon some distant object. Consciousness is abolished. 
Spasms begin in the facial muscles, then become general. 
The convulsion is at first tonic, then clonic. For a time 
the patient is asphyxiated owing to tonic spasm of the 
respiratory muscles. A few seconds later the breathing 
becomes stertorous. Froth oozes from the mouth and nos- 
trils. The tongue is usually bitten during the convulsive 
seizure and the frothy discharge bloodstained. 

The duration of the convulsion is usually one or two 
minutes. The interval between the attacks may be a few 
minutes or several hours. 

Coma follows the eclamptic seizure, generally subsiding 
within a half hour. The coma, as a rule deepens after each 
successive convulsion, owing to increasing cerebral conges- 
tion. The pulse is usually rapid, often reaching 140. The 
temperature in different cases varies from normal or sub- 
normal to 105° F. or more. The pyrexia is probably of 
toxic origin. Labor generally begins on the occurrence of 
convulsions, if not already established. 

Prognosis. The prognosis is the more grave the earlier 
the attack in pregnancy or labor. The danger increases 
with the number of convulsions. Recovery is exceptional 
after fifteen or twenty seizures and seldom occurs after a 
temperature of 105° F. A small and feeble pulse is a bad 
prognostic. Profound coma, complete suppression of urine, 
and paralysis indicate an unfavorable prognosis. Impair- 
ment of the mental faculties sometimes follows. 

The toxaemia of pregnancy in women pregnant for the 
first time after forty years of age is almost invariably fatal 
if the pregnancy is allowed to go to the later months. 

Pregnancy in primiparse, the subjects of nephritis before 
conception, is uniformly fatal if not interrupted before term 
(Tyson.) 



PATHOLOGY OF LABOR. 287 

The maternal mortality of eclampsia is from 25 to 35 
per cent, from exhaustion, asphyxia, cerebral hemorrhage, 
oedema of the lungs. The percentage of deaths from eclamp- 
sia beginning before labor is twice as great as after labor, 
one-third as great as during labor. The foetal death-rate is 
from 50 to 70 per cent., mainly from asphyxia. The toxic 
material is transmitted to the foetal blood and a certain pro- 
portion of children die after birth from this cause, usually 
by convulsions. 

Treatment. Prophylactic. A milk-diet limits the 
toxaemia. It should be given to the exclusion of all other 
food for a time. Farinaceous food, white meats and fish 
may be allowed to a limited extent as the symptoms improve. 
Free catharsis by salines and diaphoresis by hot baths, hot 
packs, and the use of sweet spirit of nitre render important 
service by supplementing the crippled elimination. Water 
is essential for diuresis; it may be given hot or half-cold, 
plain or mildly alkaline: from three to six pints may be 
taken daily. Hot fomentations and dry cups over the 
kidneys are useful for the same purpose. Nitroglycerin in 
full doses is valuable, not only as a diuretic but as a direct 
anti-eclamptic. Fluid extract of veratrum viride (Squibb), 
lruij to % vj t. i. d , or enough to hold the pulse below seventy, 
is a useful prophylactic. Chloral, 3j to 5\j daily, or the 
bromide of sodium in similar doses is one of the most useful 
agents for subduing the reflexes. Iron is frequently indi- 
cated as a restorative. Marked ursemic symptoms, a large 
proportion of albumin in the urine, or scanty urinary secre- 
tion not promptly relieved by dietetic and medicinal measures 
call for the induction of labor. 

Remedial. The principal reliance for controlling the con- 
vulsions is the combined use of chloroform inhalation, vera- 
trum viride, catharsis and the prompt evacuation of the 



288 ESSENTIALS OF OBSTETRICS. 

uterus. For the veratrum chloral may be substituted with 
nearly equal effect. Morphine gr. J to 1J hypodermically 
or morphine and veratrum may replace veratrum alone when 
the pulse is feeble. 

Pending the action of other remedies place the patient at 
once under chloroform nearly or quite to the surgical degree. 
Chloroform by inhalation is an almost certain anti-eclamptic. 
Its use is always imperative during operative interference. 
Yet prolonged chloroform narcosis is dangerous ; two or 
three hoars should usually be the limit. 

Inject subcutaneously fluid extract of veratrum viride 
(Squibb) ttlx to filxx. If at the end of a half hour the pulse 
is not below 60, inject another ten minims. A convulsion 
is substantially impossible while the circulation is sufficiently 
under the influence of veratrum to hold the pulse-rate below 
60. The patient must be required to maintain the recum- 
bent posture while using the drug in large doses. Tumultu- 
ous action of the heart ensues immediately on rising. Collapse 
under veratrum is successfully combated by the use of mor- 
phine hypodermically, or by whiskey administered in similar 
manner or by the bowel. 

Veratrum, by its effect as a vasomotor relaxant, not only 
controls convulsions but it acts as a diuretic and a dia- 
phoretic. 

Chloral is best given by the rectum in a teacupful of milk. 
The dose may be 5ss hourly till 5j or 5y have been given. 
Other anti-eclamptic measures of repute are : nitroglycerin, 
gr. ^q- hypodermically ; amyl nitrite, ti^y by inhalation ; the 
inhalation of oxygen ; venesection. 

For catharsis, calomel and salines, elaterium gr. J or croton 
oil nij to niij, may be employed. 

A cork or a folded napkin may be held between the 
patient's teeth during the convulsive attacks to prevent biting 



PATHOLOGY OF LABOB. 289 

the tongue. If the tongue obstructs respiration it should 
be drawn forward. It is sometimes useful to remove the 
mucus from the throat with a swab held in the grasp of 
forceps. 

Labor usually sets in on the occurrence of eclampsia. 
Measures are indicated to accelerate the labor if it has 
already begun, or to induce it if not spontaneously estab- 
lished. Convulsions cease in 90 per cent, of cases after 
delivery. Recourse may be had to manual dilatation of the 
cervix or to Dtihrssen's incisions in extreme cases. 

It should be stated that the induction of labor for the 
prevention of eclampsia is opposed by certain obstetric 
authorities. Its wisdom, however, either as a prophylactic 
or a curative measure can scarcely be questioned when other 
therapeutic measures have failed. 

If cardiac supports are called for, whiskey and strychnine 
are to be given p. r. n. Inhalations of oxygen are useful. 
The subcutaneous injection of the normal saline solution 
acts as a stimulant and it helps elimination. 

During convalescence the anti-eclamptic and the eliminant 
treatment are to be continued for two or three days, as 
required, and later iron and general tonics are indicated as 
restoratives. 

DIABETES MELLITUS. 

As has already been stated, sugar is sometimes to be 
found in the urine of women shortly before and for a few 
days after childbirth. Generally, the glycosuria of this 
period is a mere lactosuria, due to resorption of milk, and is 
unimportant. True diabetes mellitus is a serious complica- 
tion of labor and the puerperal state. Fortunately, it is 
rarely encountered in child-bed. Exceptionally it is a cause 
of foetal death. 



290 ESSENTIALS OF OBSTETRICS. 

CARDIAC DISEASE. 

Most valvular heart lesions are aggravated by the extra 
tax put upon the heart in the later months of gestation. 
Not infrequently they are the cause of abortion or of pre- 
mature labor. 

Advanced cardiac disease is a dangerous complication of 
labor. Engorgement of the right heart and oedema of the 
lungs often supervene. The danger is greatest at the close 
of the third stage, when a large volume of blood is abruptly 
thrown on the venous side from the uterine sinuses. Sta- 
tistics show that multiple lesions are attended with the 
greatest mortality. Mitral incompetence or especially ste- 
nosis of the mitral orifice is almost equally fatal. Next in 
gravity is aortic incompetence. 

Treatment. Before and during labor the heart should 
be actively supported. Tincture of strophantus, n^v, 
q. v. h., or fluid extract of digitalis, truj, guarded with 
trinitrin, gr. yj-g- t. i. d., should be given for several days, 
and continued during labor. Strychnine, gr. -^ t. i. d., is 
useful. Resort may be had to venesection in extreme 
venous engorgement ; the inhalation of amyl nitrite during 
the third stage is recommended ; ether should be used in 
preference to chloroform as the anaesthetic, and that only 
during the severer pains of labor. The heart must be re- 
lieved as far as possible from the strain of labor by tbe use 
of artificial aids for delivery. Ergot should be omitted, 
since a little extra blood-loss is conservative. 



CHAPTER VII. 
PATHOLOGY OF THE PUERPERAL STATE. 

PUERPERAL INSANITY. 

The mental disorder may begin during pregnancy or the 
puerperal period. In the puerperium the onset occurs most 
frequently at the end of about two weeks, seldom after five 
or six weeks. The psychical disorder very commonly takes 
the form of melancholia, sometimes of mania. 

Frequency. Puerperal insanity occurs in about 1 in 400 
puerperal women. 

Causes. Causes most frequently assigned are hereditary 
predisposition, bad mental hygiene, violent emotional dis- 
turbance, anaemia, eclampsia, exhaustion, sepsis. Of these the 
predisposing cause is sepsis. Recent investigations go to 
prove that the puerperal psychoses originate almost uni- 
formly in some form of toxaemia, especially in septic infec- 
tion. 

Prognosis. The prognosis is better in the maniacal 
than in the melancholic form. It is not so good in lacta- 
tional insanity as in cases beginning during pregnancy. A 
marked heredity is unfavorable. 

The mortality does not exceed 8 or 9 per cent. Nearly 
70 per cent, recover their reason. 

Treatment. If proper nursing can be had home 
treatment is, in mild cases at least, better than the asylum. 
Look to the mental and the physical hygiene. In the puer- 



292 ESSENTIALS OF OBSTETRICS. 

peral forms suspend nursing. Iron, pil. Blaud, one or two 
t. i. d., or arsenate of iron, gr. y 1 ^- t. i. d., is indicated in 
anpemia. The hypodermic injection of the hydrobromate of 
hyoscine, in doses of gr. T ^-g- to gr. -fa two or three times 
daily, is a useful sedative in maniacal forms. Chloral, the 
bromides, chloralamid or paraldehyd may be required as 
sedatives and hypnotics. Chloral, however, is contra- 
indicated in marked ansemia. Morphine, gr. J-, is some- 
times permissible. Intestinal fermentation and septic infec- 
tion are to treated as in other cases. 

GALACTORRHEA. 

This term applies to an excessive secretion of milk which 
persists after weaning. The quantity may reach several 
quarts daily. The quality is thin and watery. The disease 
may affect one or both breasts. It often results in serious 
impairment of the general health. 

Treatment. Treatment consists in the use of a com- 
pression breast-binder, and restriction of liquids. Potas- 
sium iodide, gr. v t. i. d., may be tried. The topical use of 
oleate of atropia may be of service. Tonics and general 
restorative measures are especially indicated. 

MASTITIS. 

Frequency. Mastitis occurs in 5 to 6 per cent, of 
nursing-women. It is met with oftener after first than 
subsequent labors. It is commoner in blondes than in 
brunettes. 

Causes. Predisposing causes of mammary infection 
are bad general health, lowering the resisting power ; milk 
stasis, injuring the vitality of the epithelium of the lactifer- 



PATHOLOGY OF THE PUERPERAL STATE. 293 

ous ducts ; lesions of the nipples, opening avenues for ab- 
sorption. The exciting cause is sepsis. The pus-producing 
organisms may gain access to the gland through nipple 
lesions, through the milk-ducts, or exceptionally by the 
blood-channels from remote septic foci. Staphylococci are 
sometimes found in the milk of healthy nursing-women. 

Forms. 1. Subcutaneous. 2. Glandular, or parenchy- 
matous mastitis ; this is in the majority of cases a lym- 
phangitis. 3. Subglandular paramastitis. Two or all these 
forms may coexist. 

Diagnosis. The subcutaneous form presents the charac- 
ters of ordinary phlegmon ; it is usually single. 

The glandular form is characterized by more pain and 
more constitutional disturbance than the subcutaneous; it 
is generally ushered in by a chill; it is often multiple; the 
gland is indurated. 

The subglandular form. In subglandular suppuration 
the temperature is persistently high, the pain is deep-seated, 
the gland is not indurated and it floats on the underlying 
fluid. The diagnosis may be confirmed by passing an ex- 
ploring-needle beneath the gland. 

Treatment. 1. Prophylactic. In simple milk en- 
gorgement, without inflammation, massage is indicated. 
The breast should be stroked gently from the base toward 
the apex. Restrict the amount of liquids ingested. Hyper- 
secretion may be relieved by saline cathartics, or in non- 
nursing patients by the topical use of oleate of atropia. 
Engorged breasts should be firmly supported with a com- 
pression binder. A pad of cotton-wool is placed under the 
binder over each breast, to distribute the pressure evenly. 
An opening in the centre of each pad relieves the nipple 
of injurious pressure. The use of a compress as tight as 
can well be borne is of great value both as a prophylactic 



294 ESSENTIALS OF OBSTETRICS. 

and a curative measure. The Murphy binder, made of a 
straight piece of muslin with a deep notch cut in one side 
for each arm and a shallow one in the centre for the neck 
is recommended. A skilfully applied roller bandage is 
most suitable when but one breast requires compression. 
Tonics, especially quinine, are useful. The aseptic manage- 
ment and curative treatment of nipple lesions are an essen- 
tial part of the treatment. 

2. Abortive. Absolute rest of the gland for one or two 
days, restriction of liquids, saline cathartics, oleate of atro- 
pia, locally, with care lest the milk secretion be too much 
repressed, quinine, gr. v to x twice daily, are useful abor- 
tive measures. 

3. Treatment of suppuration. The pus-cavity should be 
opened early and freely, with antiseptic precautions. The 
incision should radiate from the nipple the areola being 
avoided. The abscess-cavity is to be thoroughly cleansed 
and disinfected. For this purpose the peroxide of hydrogen 
is a good non-toxic disinfectant. Counter-openings may be 
necessary for satisfactory drainage. Leave a drainage-tube 
in each opening; apply antiseptic dressings and compression 
to obliterate the cavity. Cleanse antiseptically once or 
twice daily and renew the dressing. 

Treatment of Sore Nipples. 

The nipples are to be cleansed after each nursing with a 
saturated aqueous solution of boric acid. They are then 
dried and saturated with fresh cacao butter. In excoriation 
the following nipple lotion is sometimes useful : 

R . — Piumbi nitratis gr. x. 

Glycerini 3ij. 

Aquam ad ^j — M. 



PATHOLOGY OF THE PUERPERAL STATE. 295 

A soothing antiseptic dressing, and one that does not 
need to be washed off before nursing is the following : 

R.-Glyceritiamyli I .... . aa ^ss. 

Bismuthi subnitratis ) 

Cleanse the nipples with the boric acid solution after nurs- 
ing and reapply the bismuth mixture. A 2J per cent, aque- 
ous solution of carbolic acid is a good antiseptic nipple lotion. 

Should these measures fail, rest the nipple for twenty- 
four or thirty-six hours, or let the child nurse through a 
nipple shield. 

To relieve pain during nursing, apply five minutes before 
a 1 or 2 per cent, solution of cocaine previously sterilized 
by boiling. 

Fissures may be lightly touched once daily with a stick 
of nitrate of silver, first pencilling with the cocaine solution. 
Pencilling with a 1 to 5 per cent, solution of silver nitrate 
is efficacious and has the advantage over the solid stick of 
being practically painless. Painting the affected surface 
with compound tincture of benzoin several times daily is 
useful. 

PUERPERAL INFECTION. 

Puerperal infection is a wound infection identical with 
that of surgical practice. Synonyms are puerperal fever, 
puerperal septicaemia, metria. 

Frequency. In pre-antiseptic times puerperal fever 
was a common affection in childbed. The mortality from 
this cause in hospitals was from 2 to 6 per cent., and so- 
called epidemics with a death-rate of 10 per cent, or even 
more were of frequent occurrence. To-day in well-man- 
aged maternities less than a fourth of 1 per cent, of puer- 
peral women die from septic infection. 



296 ESSEXTIALS OF OBSTETRICS. 

In general private practice, without antisepsis, there is 
about 1 per cent, of septic deaths, and a large proportion of 
women who survive infection are seriously, often perma- 
nently, crippled in health. From 15 to 20 per cent, of 
women dying during the child-bearing age die of puerperal 
fever. Under a strict asepsis there are practically no deaths 
from puerperal fever in family practice, and the morbidity 
does not exceed 8 per cent.; even that is usually of a mild 
type. The disease is observed more frequently in primiparse 
than in multipara. 

Etiology. The cause is the introduction of septic germs 
into the wounds of the birth-canal during labor or the puer- 
perium. Conditions which impair the resisting powers act 
as complicating causes. The puerperal state at its best is 
one of lowered resistance. 

The sources of the infecting organisms are the lochia of 
puerperal fever patients, secretion from suppurating wounds, 
erysipelas, diphtheria, and in certain cases scarlet fever or 
typhoid fever owing to complications involving the presence 
of wound-infection germs, also cadaveric and other dead and 
decomposing animal matter. Gonorrhoea is sometimes the 
source. Self-infection — auto-infection — in the true sense of 
the term does not exist. The term as now used is applied 
to infection from septic matter primarily present in the 
genital tract. Infection from the latter source is probably 
possible only in diseased conditions of the genital mucosa. 

Vehicles of infection are the hands of the obstetrician or 
the nurse, instruments, utensils, cloths, germ-laden dust, etc. 

The avenues of absorption are the obstetric wounds of the 
vulva, vagina, the cervix and corpus uteri, and even intact 
surfaces of the genital mucous membrane. Systemic infec- 
tion and that of the uterine adnexa spring most frequently 
from the cavity of the uterus, especially from the placental site. 



PATHOLOGY OF THE PUERPERAL STATE. 297 

The channels of diffusion are usually the lymphatics, less 
frequently the veins. 

Bacteriology. The organisms most constantly concerned 
are the streptococci ; staphylococci are frequently met with." 
The bacterium coli commune, the gonococcus, the bacillus of 
diphtheria and certain other microorganisms are occasional 
factors in the pathogeny. Putrefactive bacteria are gen- 
erally present. Putrefaction of lochia produces a soil favor- 
able for the development of pathogenic organisms. The 
putrefactive bacteria act solely, others largely, by the effects 
of their chemical products, ptomains. 

Special Manifestations are : Endometritis ; salpin- 
gitis; oophoritis: metritis; parametritis; perimetritis or 
pelvic peritonitis ; diffuse peritonitis : uterine lymphangitis 
and phlegmonous lymphadenitis — generally accompanied 
-with peritonitis; phlebitis — uterine, peri-uterine, and crural; 
colpitis ; pure septicaemia : acute ptomain-poisoning — putrid 
intoxication ; saprsemia ; pya?mia ; cystitis ; uretero-pye- 
litis, pneumonia, pleurisy, pericarditis, endocarditis, nephritis, 
arthritis, subcutaneous phlegmons, and others. 

Diagnosis. General symptoms of infection. Usually 
the first symptoms appear on the second or third day after 
labor, rarely later than the fourth or fifth, since the obstetric 
wounds have by that time begun to granulate, and the granu- 
lation laver acts as a barrier to the invasion of the pvogenic 
organisms. In the majority of cases the disease begins in- 
sidiously. The attack is sometimes ushered in by a more or 
less pronounced chill. 

The most conspicuous early symptoms are rapid pulse, 
100 to 140; rise of temperature, 102° to 104° F.. fetid 
lochia — yet sepsis often occurs without fetor. The bad odor 
is due to the presence of putrefactive bacteria or of the colon 
bacillus, and is often absent at the onset of sepsis in the most 



298 ESSENTIALS OF OBSTETRICS. 

virulent forms of puerperal infection. Exclude malarial 
pyrexia by quinine or better by microscopic examination of 
the blood for plasmodia malarise ; exclude also pneumonia, 
typhoid fever, fecal retention, emotional, mammary and 
other non-septic causes of high temperature. 

Symptoms of Special Lesions. 

Endometritis. This is the lesion most constantly present 
in puerperal sepsis. The uterus is more than normally sen- 
sitive on palpation over the lower abdomen ; the cervix is 
more patulous than normal for the time ; the uterine lochia 
are often foul ; the bloody flow is usually prolonged. Gen- 
erally owing to a greater or less degree of accompanying 
metritis the uterus is somewhat boggy, tender on pressure 
and involution is retarded. 

Sometimes the septic process is limited to the endometrium, 
the organisms not penetrating beyond the granulation-zone. 
When for any reason that protection fails the sepsis becomes 
widespread and the systemic disturbance proportionately 
greater. Occasionally in profound general sepsis the endo- 
metritis may be insignificant owing to early migration of the 
offending organisms into other structures. 

Metritis. This originates in a lymphangitis of the 
uterine walls. It is most frequently secondary to an endo- 
metritis. Portions of the muscularis may slough — dissect- 
ing metritis. After-pains are severe and prolonged. The 
uterus is large, soft and boggy and tender to the touch. 

Parametritis and Perimetritis. There are pain and 
tenderness at the seat of inflammation, moderate tympan- 
ites, frequently nausea ; the lochia are scanty ; an exudate 
is found in one or both broad ligaments by abdominal or 
bimanual examination ; the uterus is more or less fixed, 
sometimes displaced ; fluctuation can generally be made out 



PATHOLOGY OF THE PUERPERAL STATE. 299 

at the seat of the exudate if pus forms. Abscess results in 
20 per cent, of cases. The pus-collection may be in the 
broad ligament, extra-peritoneal, or it may be intra-perito- 
neal and encysted, the result of a circumscribed peritonitis 
and agglutination of surrounding structures, or of walling 
off by exudate. 

Diffuse Peritonitis. The route by which the pyogenic 
organisms reach the peritoneum is almost invariably the 
lvmphatics. There are exquisite abdominal pain and tender- 
ness in the early stages generally ; later tenderness may 
partially or wholly disappear. Tympanites is usually ex- 
treme. There is vomiting of greenish fluid, diarrhoea, and 
finally collapse. The termination is almost surely fatal 
within a week. 

Phlegmasia Alba Dolens, Milk-leg, is essentially a phlebitis 
of the lower extremity. Its origin is a uterine phlebitis. 
The period of invasion varies from two to three or four 
weeks after delivery. Its occurrence implies a pre-existing 
endometritis and infection of thrombi in the mouths of 
the uterine sinuses at the placental site. . The evidence 
of uterine sepsis, however, may be so slight as to escape 
observation. The attack is sometimes ushered in by a chill, 
and is always attended with pain and swelling in the affected 
limb. The pain is first felt in the groin, and usually ex- 
tends throughout the length of the thigh and leg within a 
few hours. The limb becomes swollen, tense, hard, white, 
glistening. The affected veins may sometimes be felt on 
palpation, as hard, irregular cords. They are frequently 
nodular, owing to the formation of thrombi. The fever is at 
first of a remittent, then an intermittent type. Resolution 
generally begins after about two weeks. The duration of 
the disease may be many weeks ; abscess-formation or gan- 
grene sometimes supervenes. There remains more or less 



300 ESSENTIALS OF OBSTETRICS. 

oedema on standing or walking, with impairment of mus- 
cular power. In a certain proportion of cases the disabil- 
ity may last for months or indefinitely. A possible termina- 
tion is sudden death by pulmonary embolism from the 
detachment of a portion of a blood-clot. Recurring chills 
are a signal of metastatic affections. The disease may 
extend from one limb to the other. 

Colpitis. The usual evidences of vaginal inflammation, 
catarrhal, phlegmonous, ulcerative or diphtheritic, are pres- 
ent ; in ulcerative vaginitis the labia are often oedematous. 
In the phlegmonous form abscess may result. Membranous 
exudates are very rarely due to a true diphtheria, usually 
to infection with pyogenic organisms. 

Pure Septicaemia is characterized by fever with absence 
of appreciable organic lesions ; the countenance is sallow, 
sunken, anxious. Occasionally there is delirium or coma ; 
diarrhoea and vomiting of dark grumous ejecta are fre- 
quently observed It runs a rapid course, often terminating 
within two or three days. 

Pymseia. Pyaemia originates most frequently in infection 
of the mouths of veins at the placental site. The phlebitic 
process may be limited or diffuse. By the breaking down 
of infected thrombi, septic emboli and metastatic abscesses 
in various parts of the body may result. Septic pneumonia 
is a common complication. 

Pyaemia is distinguished by irregularly recurring chills, 
marked irregularity of the temperature, and by metastatic 
development of purulent foci. The duration may be many 
weeks. Often it progresses to a rapidly fatal termination. 

Cystitis is attended with vesical tenesmus and increased 
frequency of urination. In the acute stage the tenesmus 
is almost constant, and is not relieved by emptying the 
bladder. Pain is sometimes excessive, and there is usually 



PATHOLOGY OF THE PUERPERAL STATE. 301 

some elevation of temperature. The urine is cloudy and of 
feebly acid reaction; sometimes it is fetid. 

Uretero-pyelitis. In uretero-pyelitis there is frequent desire 
to urinate, with pain and tenderness along the inflamed 
tract. Pressure on the ureter through the vagina by con- 
joined manipulation elicits pain and desire to urinate. The 
urine is acid and contains pus and blood. The temperature 
is very high in the acute stage. 

In most cases of puerperal infection several of the 
lesions above described coexist. 

Prognosis. As a rule the earlier the attack the more 
unfavorable the prognosis. It is gravest in acute putrid 
intoxication, diffuse purulent peritonitis, pysemia. Gener- 
ally the prognosis is best when the septic process is dis- 
tinctly localized. 

Treatment. Prophylactic. To prevent infection en- 
force a rigorous asepsis of the hands, instruments, utensils, 
and of everything that comes in contact with the genitals 
during labor and the puerperium. Cleanse antiseptically the 
external genitals, lower abdomen and inner surfaces of the 
thighs before internal examinations. Disinfect the vagina 
and cervix before and during labor for cause. Examine 
by the vagina during labor as seldom as possible. In 
most cases vaginal examinations may, when, for any reason, 
more than ordinary care is required, be omitted altogether. 
Prevent all preventable injuries of the passages. Under 
modern methods of prophylaxis there should be practi- 
cally no mortality from puerperal infection in private 
practice. 

Remedial. General treatment of infection. The treat- 
ment may be summed up in a few words : Dislodge the 
enemy, when possible, and reinforce the resisting powers of 
the patient. 

14 



302 ESSENTIALS OF OBSTETRICS. 

Catharsis. On the first rise of temperature give calomel, 
gr. v to gr. x, and follow with a saline, Epsom salt. 

Repeat the saline, as required, to procure three or four 
watery movements daily, if the strength of the patient per- 
mits. Hypercatharsis applies especially to the first few days 
of the fever, and should be continued only so long as the 
temperature and other symptoms improve under it. 

Spontaneous diarrhoea is generally conservative, and 
should not be checked unless excessive. Should it be neces- 
sary, the subnitrate of bismuth, gr. x q. 2 to 4 h., may be 
given. A pelvic examination should be made to determine, 
if possible, the seat of infection. 

Vaginal Disinfection. Vagina alone involved, douche 
with a 2 to 3 per cent, solution of hydrogen peroxide, a 1 in 
10 to 15 dilution of Labarraque's solution or a 2 per cent, 
carbolic solution. If the temperature falls, repeat the 
douche as soon as it rises again. Ulcers and necrotic or 
pseudo-diphtheritic patches should be touched once or twice 
daily with tincture of iodine, a 50 per cent, chloride of zinc 
solution, or with carbolic acid. Before any interference 
within the passages as rigorous an antiseptic preparation 
is required as for a major surgical operation. 

Curettage of the Uterus. Uterus septic, give a prolonged 
intra-uterine douche with one of the foregoing solutions 
or with the normal saline solution, and curette the entire 
cavity thoroughly. Irrigate again and pack with iodoform 
gauze. Remove the packing in one or two days. The 
intra-uterine measures should not, as a rule, be repeated. 
If, however, the lochia are still foul douching with the salt 
solution or plain sterilized water should be repeated two or 
three times daily, only so long as the temperature falls after it. 

Curetting is especially applicable in saprsemic cases, and 
in most others within the first two or three days of the 



PATHOLOGY OF THE PUERPERAL STATE. 303 

puerperium. Later, after the granulation zone is estab- 
lished, a prolonged irrigation followed by painting the 
entire cavity with tincture of iodine may be substituted. 

Support the patient with tonics, stimulants and forced 
feeding. Give strychnine, gr. ^ to gr. J ¥ , hypodermically 
every four hours, and brandy to the extent of a pint or 
quart daily; instead of brandy, whiskey or an equivalent 
of wine may be preferred. To realize the full benefit of 
the alcohol it should be pushed to the point of intoxication. 
The subcutaneous injection of a pint to a quart of the 
normal salt solution daily is sometimes of great service as 
a stimulant and eliminant. 

Antipyretics. Reduce the temperature by cold spong- 
ing, cold packs, or the use of a cold coil. 

The coal-tar antipyretics serve only to mask the symptoms 
and are depressing and otherwise injurious. Quinine is use- 
less in purely septic fever except in small doses, gr. ij 
or iij t. i. d., as a tonic. Even for the latter purpose it is 
inferior to strychnine. 

Narcotics. An occasional opiate in small doses, mor- 
phine, gr. J, or codeine, gr. J, may rarely be required in 
case of extreme nervous excitement or sleeplessness, but 
should be withheld if possible. 

Treatment op Peritonitis. Saline cathartics, with large 
stimulating enemata, to procure several copious evacuations 
daily are often of service. Moderate doses of opium will rarely 
be needed for control of pain and restlessness. Dietetic 
supports, tonics and stimulants are the chief reliance in sys- 
temic infection. The utero-vaginal tract should be kept 
free from necrotic and septic material. In localized puru- 
lent peritonitis open the abdomen, cleanse and drain the 
pus-cavity. The drainage should be established through a 
posterior vaginal incision if possible, and the suprapubic in- 



304 ESSENTIALS OF OBSTETRICS. 

cision closed. In diffuse peritonitis abdominal section is rarely 
successful. Gauze drainage of the peritoneum through the 
posterior vaginal fornix might be of service at the beginning 
of a peritonitis. 

Treatment or Parametritis. Hot vaginal douches, 
several gallons at a temperature of 110° to 120° F., may 
be given two or three times daily. Local antiseptic and 
general tonic measures are indicated as in other septic con- 
ditions. If abscess forms evacuate early and drain by the 
vagina or abdomen. Operation by the vagina is generally 
safest and it effects the best drainage. This route should be 
chosen except when the pus-cavity cannot safely be reached 
from below. In the latter event the incision should be 
made just above Poupart's ligament and parallel with it. 

Treatment of Phlegmasia Alba Dolens. The limb 
should be kept at rest in a horizontal position. Pain may 
be subdued by the local application of oleate of morphia. 
After the application the limb is enveloped with a single 
thickness of muslin wrung out of hot water, and this covered 
with oiled silk. Avoid massage during the active stage of 
the disease; it may cause embolism. Should abscesses form 
they should be treated by early and free incision, followed 
with thorough cleansing and drainage. The patient may 
leave the bed when the swelling subsides and the fever has 
long since ceased. From that time the affected limb should 
be supported by means of a flannel bandage or an elastic 
stocking. The support should be continued so long as 
much swelling occurs on standing or walking. 

Treatment of Pyaemia. The general treatment is 
essentially the same as in septicaemia. Metastatic pus-foci 
should be opened and drained if accessible. 

Treatment of Cystitis. A mildly alkaline water should 
be drunk freely as a diluent. The bowels must be kept 



PATHOLOGY OF THE PUERPERAL STATE. 305 

freely open, and the diet should be non-stimulating. Sweet 
spirit of nitre, four to six times daily, helps to relieve pain. 
When the acute stage has passed oil of sandalwood in doses 
of 10 to 20 drops from three to six times daily is most useful. 
Treatment of Uretero-pyelitis. Water is to be used 
freely by the stomach or by high rectal injections to flush 
the septic tract by increased secretion of urine. Salol in 
doses of five grains every three hours is useful as an anti- 
septic. Here, as in cystitis, the oil of sandalwood is especi- 
ally valuable. Irrigation of the inflamed ureter through a 
ureteral catheter is most effective, but this is to be attempted 
only by an expert. The cystitis must be treated. 

SUDDEN DEATH IN CHILDBED. 

Among the principal causes of sudden death in childbed 
those most frequently encountered are shock, syncope, pul- 
monary embolism, acute pulmonary oedema, apoplexy, 
advanced cardiac disease. 



CHAPTEE VIII. 
OBSTETRIC SURGERY. 

INDUCTION OF PREMATURE LABOR. 

Indications are certain cases of narrow pelvis, in which 
the delivery of a living and viable child is thus possible, 
flattening to between 7 and 9 cm. (2f to 3J inches) or 
equivalent contraction of other forms ; foetal death ; habitual 
death of the foetus in the last month of gestation from 
other causes than syphilis ; nephritis of pregnancy, drug 
and dietetic measures failing; dangerous cases of placenta 
prsevia, after the period of viability, and accidental hemor- 
rhage ; certain cases of hydramnios, with danger to mother 
or child. 

1. Pelvic contraction. Here the most difficult problem 
is to fix the proper time for interference. Operating too 
soon, the interests of the child, too late, those of the mother, 
are imperiled. The most reliable data for deciding the ques- 
tion are afforded by careful measurements of the pelvis and 
of the child, especially the foetal head. Crowd the head 
into the pelvic brim with one hand over the abdomen while 
the other is passed internally to learn how far and with how 
much freedom the head descends. The labor should be 
brought on as soon as, under repeated examinations at in- 
tervals of one or two weeks, the head is found to enter the 
pelvis with difficulty. 

2. Habitual death of the foetus. Operate a week or two 



OBSTETRIC SURGERY. 307 

before the usual period of the foetal death. The strength 
and frequency of the foetal heart and the vigor of the foetal 
movements must be closely watched as the fatal period ap- 
proaches. 

3. Nephritis. The pregnancy should be terminated on 
the appearance of grave symptoms, especially if the foetus 
has reached the full period of viability and medical and 
dietetic treatment have failed. 

4. Hemorrhage. In placenta prsevia and in accidental 
hemorrhage, after the period of viability, it should be the 
rule to induce labor as soon as the diagnosis is established. 

5. Hydr amnios. Here interference is called for when 
the life of mother or child would be jeopardized by longer 
continuance of the pregnancy. 

Methods, (a.) Catheterization of the Uterus. First step. 
Separation of the membranes from the lower uterine segment 
by means of a uterine sound or with the finger. 

The cervical canal and the vagina must first be rendered 
aseptic. Detachment of the membranes with the sound 
may be done with the woman either in the left lateral or 
the dorsal recumbent position. For the use of the hand the 
dorsal position is best. 

Second step. Insertion of one or more English bougies 
between the membranes and the uterus. 

Usually the bougie is most readily passed with the aid of 
the Sims position, the cervix being drawn forward and held 
with a volsella. The bougie is sterilized by boiling or 
steaming, the proximal end is cut off and a stylet inserted. 
Great care must be used to avoid rupturing the membranes. 
The instrument is pushed up gently and in the direction 
in which it passes most easily. The bougie once in place 
the stylet is withdrawn. A second bougie may be inserted 
if it can be pushed into place without too much difficulty. 



308 ESSENTIALS OF OBSTETRICS. 

A light tampon of iodoform gauze may be packed in the 
vagina, but it is not required to support the bougie. The 
instrument is left to be expelled with the child. Labor is 
usually established within one or at most two days. This 
method is not suited to cases in which immediate delivery 
is called for. 

(5.) Tamponade of the cervical canal and the vagina with 
iodoform or borated gauze. The gauze is applied in long 
strips, with the patient in the Sims position, and the peri- 
neum well retracted with a Sims speculum. The tampon- 
ade must be as firm as it can be made, and must completely 
fill the vagina and be held in place by means of a T-bandage. 
The cervix and vagina should be sterilized before packing. 
The gauze tampon is renewed daily till labor is established, 
the vagina and the cervical canal being douched with one of 
the mercurial solutions before repacking. The method acts 
slowly, and is therefore unsuitable when prompt delivery 
is demanded. It is especially adapted to cases of hemor- 
rhage. 

(<?.) Dilatation of the Cervix. The woman is placed in 
the lithotomy position under an anaesthetic. The vulvar 
hair is clipped short. The external genitals and vagina are 
scrubbed for three minutes with soap and hot water by the 
nurse. For this purpose she may use a brush or the hands, 
previously sterilized. The vagina is then douched to wash 
away the mucus. The operator repeats the soap and water 
scrubbing, using sponge compresses held in the grasp of 
straight forceps. Finally, the vagina is douched and the 
external parts washed for five minutes with one of the 
mercurial solutions, using gentle friction with sponge com- 
presses frequently renewed. The cervical canal is cleansed 
with equal care. The operator then lubricates his hand 
well with aseptic glycerin. Coning the fingers the hand 



OBSTETRIC SURGERY. 309 

is introduced into the vagina. One finger is passed 
through the cervix. After a time the cervix relaxes 
till a second finger can be passed, then one finger after 
another until the whole hand is introduced. The fist is 
then slowly and cautiously closed in the grasp of the cervix. 
By this time the dilatation is sufficient for the passage of 
the head, and at the same time active uterine contrac- 
tions have been established. The dilatation must be done 
with the least possible muscular eifort, to prevent cramp- 
ing of the hand. To prevent laceration of the cervix ex- 
treme care must be used, taking plenty of time for each 
step. The danger of tearing is greatest in the latter part 
of the dilatation. Should the indications warrant imme- 
diate extraction may be undertaken by version or forceps. 
Delivery is thus possible within fifteen minutes to two or 
three hours, according to the rigidity of the cervix and the 
difficulty of extraction. 

When the cervical canal is too small to easily admit the 
finger the dilatation may be commenced with a branched 
steel dilator. Or, if time permits, a cervical and vaginal 
tampon may be placed and left for twenty-four hours. By 
the end of that time the cervical canal will be found suffi- 
ciently expanded to receive the finger. 

The method of artificial delivery by rapid dilatation of the 
cervix is a dangerous one except at the hands of a trained and 
skilful operator, and is to be reserved for use in emergencies 
only. No important injury need result from lacerations of the 
cervix if they are properly sutured at the close of labor, but 
without the greatest caution the tear may extend into the 
lower uterine segment and even into the peritoneum. Dila- 
tation of the cervix by means of water-bags is tedious, but 
is generally safer, and is to be preferred when the indica- 
tion for delivery is not too urgent. (Figs. 62, 63, 64.) 

14* 



310 



ESSENTIALS OF OBSTETRICS. 

Fig. 62. 




Barnes' dilating water-bags. 
Fig. 63. 




McLean's bag. 
Fig. 64. 




Champetier de Ribes bag 



BSTETRIC S UEGERY. 31 ] 

(d.) Glycerin Injection. The intra-uterine injection of 
glycerin acts to provoke uterine contractions by reason of 
its effect as a direct irritant, by peeling up the membranes 
and by causing a shrinkage of the amniotic sac through its 
exosmotic action. Labor generally begins within two or 
three hours. Occasionally the injection may require repe- 
tition, or it may fail altogether. A serious objection to 
this method is the fact that hemoglobinuria is frequently 
induced by the effect of the glycerin upon the blood, espe- 
cially when two or three ounces have been injected. Ne- 
phritis may result, or existing disease of the kidneys be 
aggravated. The injurious effects of the glycerin are pos- 
sibly in great measure preventable by limiting the quantity 
to a half ounce. 

(e.) Diihrssen's Incisions. In this operation four longi- 
tudinal incisions are made in the cervix at equal intervals. 
They are best located a little to one side of the anterior, the 
posterior, and right and left aspects of the cervix. They 
should extend to the vaginal junction. With the patient 
in the dorsal position and the cervix drawn down with a 
volsella, and using two fingers of the left hand as a guide, 
one within and the other without the cervix, the cuts are 
made with a pair of strong straight scissors. The method 
is applicable only after dilatation has progressed far enough 
to obliterate the internal os. The preliminary dilatation may 
be accomplished by manual or instrumental interference, if 
it has not already taken place spontaneously. The opera- 
tion, when done as described, affords ample space for ex- 
traction of the child. The incisions may be closed, after 
delivery, by immediate or by secondary suture. 

Care of the Child. In case of premature children the 
use of an incubator will generally be required. In hospital 
practice an Auvard's, Crede's, Rotch's or Marx's apparatus 



312 ESSENTIALS OF OBSTETRICS. 

should be provided. For use in private practice an impro- 
vised incubator of wood or metal may readily be constructed. 
It should have a removable cover and a false bottom. The 
child is placed in the upper chamber and hot bottles, or 
a metal water tank heated by an alcohol lamp in the 
lower. Air admitted to the lower chamber flows into the 
upper through several half-inch perforations at one end of 
the false bottom, escaping by similar perforations at the 
opposite end of the top or cover. A thermometer in the 
upper chamber should constantly register about 90° F. A 
glass window in the top of the incubator permits observation 
of both child and thermometer. The usual period of incu- 
bation is from one to three months. Meantime the child is 
removed from the warm chamber only for nursing, bathing, 
and changing of clothing. 

Recourse must be had to gavage, or feeding through a soft 
stomach-tube, when the child is unable to nurse the breast 
or bottle or to be fed from a spoon. By incubation and 
gavage 20 per cent, of children born at the sixth month may 
be saved. The viability is correspondingly greater in more 
advanced stages of gestation. 

INDUCTION OF ABORTION. 

Indications. 1. Pregnancy nephritis with grave symp- 
toms not yielding to other measures ; chronic nephritis. In 
chronic nephritis the termination of the pregnancy is de- 
manded because development to viability and the birth of a 
living child are exceedingly rare and the child if born alive 
is puny and feeble. The mother's life, too, is seriously 
jeopardized by the continuance of the pregnancy. Even if 
she survives the pregnancy and the labor grave injury will 



OBSTETRIC SURGERY. 313 

have been done to the crippled kidneys by the extra tax put 
upon them by the pregnancy. 

2. Uncontrollable vomiting of pregnancy. Medicinal 
and dietetic measures failing, the uterus should be emptied 
before the occurrence of grave symptoms. 

3. Extensive vesicular degeneration of the chorion. The 
diagnosis established and no evidence of foetal life being dis- 
covered, the uterus should be promptly evacuated. 

4. Irreducible retroversion of the gravid uterus. The 
retroverted gravid uterus is very rarely irreducible, especially 
before the third month. Before resorting to abortion, the 
usual measures for reduction, with the woman in the Sims 
or the genu-pectoral position, should have had a fair trial. 

5. Absolute contraction of the pelvis. The termination 
of the pregnancy in the early months is demanded, on 
election of the mother, especially in conditions unfavorable 
for cceliotomy. This applies to contraction of the soft parts 
and to obstructing tumors as well as to distortion of the 
bony pelvis. 

6. Pernicious ancemia. 

7. Chorea. Chorea as a complication of pregnancy is 
generally an intractable disease and sometimes dangerous to 
life. 

8. Death of the ovum calls for evacuation of the uterus 
immediately the diagnosis of death of the foetus can be posi- 
tively established. 

9. Chronic heart disease. In advanced cardiac disease 
the heart suffers impairment owing to the extra tax to which 
it is subjected in the later months of pregnancy, and the life 
of the patient is seriously jeopardized at labor. 

Methods. 1. Detachment of the ovum and tamponade 
of the cervix. Abortion may be induced by partially de- 
taching the ovum with a uterine sound aseptically, or by the 



314 ESSENTIALS OF OBSTETRICS. 

use of the cervical and vaginal tamponade with iodoform or 
boric acid gauze as already detailed under induction of 
premature labor, or these procedures may be employed con- 
jointly. The tampon is renewed after twenty-four hours. 
The strictest asepsis must be observed. 

2. Immediate evacuation of the uterus with the curette 
is the method preferred by the writer. The patient is placed 
under an anaesthetic in the lithotomy or Sims position. The 
external genitals and the vagina are scrubbed for five minutes 
by the nurse with soap and hot water. The operator then 
douches the vagina and again scrubs the vagina and vulva 
and immediate surroundings with soap and hot water, using 
friction over the mucous surfaces with cheese-cloth compresses 
frequently renewed. For cleansing the skin a soft aseptic 
brush or the hand may be used. The vagina is douched 
again with one of the mercurial solutions for five minutes 
and the external surfaces washed with the same, using fric- 
tion with fresh compresses. The cervix is exposed by the 
aid of a Sims speculum, is drawn down with a volsella, and 
its canal is also cleansed and disinfected. The cervix is 
now dilated sufficiently to easily admit the largest curette to 
be used, care being taken to avoid lacerating the tissues. 

When the gestation has not advanced beyond the second 
month, the ovum may be broken up with the curette and 
entirely scraped away. 

A pair of Keith's or similar straight forceps will be 
found useful for the removal of debris that is not brought 
away by the curette or by douching. The curetting is best 
done with a sharp curette and should be continued till the 
decidua has been removed. 

The operator knows by the peculiar grating sound and 
by the harsh feel when the instrument has reached the 
uterine wall. The ovum or the decidua has a smooth or 



OBSTETRIC SURGERY. 315 

spongy feel, and gives out no sound as the curette is drawn 
over it. The sharp curette does its work with much lighter 
pressure than the dull instrument and, therefere, with less 
injury by bruising; with proper care it willnot cut too 
deeply. The uterine cavity is finally douched thoroughly 
with a t 7 q- per cent, salt solution or with plain sterilized 
water. A half drachm of fluid extract of ergot may be 
given hypodermically as a precaution against hemorrhage. 
In aseptic conditions no drain is required and no vaginal 
dressing. 

When the contents of the uterus have become necrotic 
the cavity should be irrigated with the mercurial or other 
equally active antiseptic solution. In such cases, too, the 
uterus should be packed lightly with iodoform gauze after 
curetting. The gauze usually becomes foul and must be 
removed in one or two days. Repacking is seldom advis- 
able. When the gestation has advanced much beyond the 
second month the dilatation may be begun with the steel 
dilator and completed with the fingers. The foetus is 
brought down and extracted by seizing the feet and the 
secundines delivered by conjoined manipulation. For 
manual evacuation the patient should be in the dorsal 
recumbent position. 

For the protection of the physician it is a rule of prac- 
tice never to induce abortion except with the approval of 
competent counsel. 

REMOVAL OF AN ABNORMALLY ADHERENT 
PLACENTA. 

Note. The existence of abnormal adhesion of the pla- 
centa may be assumed, as a rule, when the after-birth cannot 
be delivered entire by ordinary external and internal man- 



316 ESSENTIALS OF OBSTETRICS. 

ual methods within two hours after the birth of the child. 
Mere retention, however, by partial closure of the retraction- 
ring must not be mistaken for adhesion. 

Etiology. The etiology is not definitely understood. The 
cause of pathological adhesions of the placenta resides prob- 
ably in a diseased condition of the endometrium antedating 
the pregnancy and resulting in deciduitis and placentitis- 
It should be remembered that an abnormally retained pla- 
centa is, as a rule, at least partially adherent and that the 
adhesion is very seldom pathological except in persistence. 
Unnaturally firm adhesion of the kind which is attributable 
to inflammatory causes is extremely rare. 

Treatment. The treatment is separation and extrac- 
tion of the placenta with the hand in the uterus. The 
separation is begun at the portion already detached. Care 
must be taken that no fragments remain. Give a hot intra- 
uterine douche of a 2 per cent, solution of creolin or of hot 
saline solution. Inject 30 minims of fluid ergot hypoder- 
mically. Bear in mind that the manual removal of an adhe- 
rent placenta is always attended with serious risk of infection. 

FORCEPS. 

The Instrument. The obstetric forceps consists of two 
crossed arms locking at the point of intersection. Each 
arm has four parts, handle, shank, lock and blade. The 
blades are shaped to grasp the foetal head as with a pair of 
hands. They are also curved in conformity with the direc- 
tion of the birth-canal. For lightness as well as for wider 
distribution of the pressure the blades are fenestrated. 
When the instrument is locked the handles fall nearly 
together, affording a convenient grasp for the operator's 
hand in applying traction. A forceps for general use 



OBSTETRIC SURGERY. 317 

should be about 38 cm. (15 inches) long, and should have 
a moderate pelvic curve and an elliptical cranial curve, 17 to 
18 cm. (about 7 inches) long, and 7.5 cm. (3 inches) in 
width externally at the widest part. The space between 
the tips of the blades when the instrument is closed should 
be 1.3 cm. (about J- inch). To admit of sterilizing by 
heat it is best made wholly of metal. (Fig. 65.) 

Fig. 65. 




The author's forceps. 

It should be thoroughly cleansed with soap, hot water, 
and a brush after using ; should always be sterilized, best 
by boiling in the soda solution immediately before using. 
It should be kept free from rust and well polished and the 
nickel plating must occasionally be renewed. 

Mechanical Action. The essential function of the 
forceps is traction. 

Its use as a lever, by means of a pendulum motion during 
extraction, is a mechanical gain, but is liable to injure the 
maternal soft parts. The practice of using the forceps as a 
lever is to be condemned. 

Compression of the head with forceps is attended with 
danger to the child and but little mechanical advantage for 
extraction. In most seizures compression of one is compen- 
sated by elongation of another transverse diameter. More 
may be gained by slow delivery, permitting time for mould- 
ing of the head under the pressure of the pelvic walls. The 
pressure of the blades should be kept at a minimum, and if 



318 ESSENTIALS OF OBSTETRICS. 

possible should be light enough to leave no marks upon the 
child. 

Indications for Forceps. 1. Forces at fault. Cephalic 
presentation in which the natural powers are clearly inade- 
quate ; generally — not always — when the head has remained 
stationary for a half hour after two hours in the second 
stage. 

2. Passages at fault Flattening, not below three and 
one-half inches, in the true conjugate, or equivalent ob- 
struction ; partial obstruction in the soft parts. As a rule, 
the forceps is permissible only after the head has engaged 
or can be made to engage. As a rule symphysiotomy is 
better than a very difficult forceps extraction. 

3. Child at fault. Among the indications for forceps 
presented by the foetus are: Arrested occipi to-posterior posi- 
tions, arrested face presentation in anterior position, moder- 
ate hydrocephalus, after-coming head, impacted breech, 
foetal pulse above 160 or below 100. In impacted malposi- 
tions of the head and in irreducible face or brow presenta- 
tion symphysiotomy may be considered. 

Complicated Labor. Forceps is often required in emer- 
gencies arising from other causes than faulty mechanism 
and in which immediate delivery is indicated in the interest 
of mother or child. This indication may be present before 
the head engages. Under this head may be mentioned 
certain cases of accidental hemorrhage, prolapsus funis, 
rupture of the uterus, and of eclampsia, for rapid de- 
livery, or of placenta prgevia to hold the head down as a 
tampon. 

Contraindications are : Head incapable of engagement, 
pelvic contraction below 3J inches, c. v., head hydrocephalic 
or macerated or perforated, cervix not fully dilated and un- 
dilatable. 



OBSTETRIC SURGERY. 319 

Dangers of the Forceps Operation, (a.) To the mother. 
Possible injuries, especially in unskilful use of forceps are: 
In the low operation vaginal lacerations and injuries to the 
pelvic floor ; in the high operation contusion and laceration 
of the cervix, or even the body of the uterus, shock and 
sepsis. Separation of the pelvic joints has resulted from 
the use of excessive and misdirected force. 

(b). To the child. Brain injuries and especially rupture 
of cerebral vessels by compression are not infrequent. Per- 
manent mental and physical infirmities and even death some- 
times result from difficult forceps delivery. Temporary 
paralysis of the facial nerves frequently occurs. Duchenne's 
paralysis may result from the effect of stretching the nerve- 
trunks that enter into the brachial plexus. An uncleanly 
and unskilled forceps delivery is a dangerous operation for 
both patients, especially in high applications. 

Application of Forceps. Preparatory measures. The 
patient is usually placed on the bed, or better on a table in the 
dorsal recumbent posture — the American obstetric position. 
In difficult high forceps operations the Walcher position 
may be utilized as follows : The patient lies flat on her back 
on the table with the hips overreaching the edge and with 
the thighs hanging in extreme extension. In this position, 
owing to nutation of the sacrum, there is a perceptible 
lengthening of the antero-posterior diameters of the pelvis 
at the brim. On the other hand, at the outlet of the bony 
pelvis the lithotomy position offers the greatest advantage, 
tilting the lower end of the sacrum backward. 

The woman should be anaesthetized and the hips brought 
close to the edge of the bed or table. The bladder and 
rectum must be empty. Examine the foetal heart before 
and occasionally during the operation. The abdomen, the 
thighs, and the external genitals must be cleansed and dis- 



320 



ESSENTIALS OF OBSTETRICS. 



infected as for a major surgical operation. No vaginal anti- 
sepsis is required except after recent uncleanly contact or in 
the presence of a pathological vaginal secretion, purulent, 
greenish, yellowish, or ill-smelling. The instruments and 
the operator's hands and arms must be aseptic. The forceps 
blades may be lubricated with vaselin or glycerin which 
has been sterilized by heat, or simply be dipped in the anti- 
septic solution. A table oil-cloth, a rubber sheet, or an 
old rug is placed under the operator's feet to protect the 
carpet from being soiled by the discharges. 



Fig. 




Application of first blade of forceps. 



Application. The left arm of the forceps is taken in the 
left hand and the blade passed on the left side of the pelvis 
during an interval between the pains. It is at first held 
nearly in a vertical position and lightly as a pen is held. 



OBSTETRIC SURGERY. 



321 



Two or more fingers of the right hand are passed between the 
head and the left wall of the passages, the palmar surface in- 
ward ; the fingers are pushed to the base of the skull if possi- 
ble. The blade is passed along the palmar surface of the right 
hand between the head and the wall of the birth-canal, follow- 
ing both the pelvic and the cranial curves, hugging the head. 
(Fig 66.) After the blade has entered the passages the handle 

Fig. 67 




Application of second blade. 



may usually best be held in the full hand. No force must be 
used. The right blade is introduced in similar manner, the 
left hand serving as a guide. (Fig. 67.) The blades are then 
adjusted in the best possible grasp as nearly over the transverse 
diameter of the head as possible. The blade is pushed into 
position by the use of one or two fingers against its poste- 
rior edge. In high applications sink the handles as far 



322 



ESSENTIALS OF OBSTETRICS. 



backward as the perineum will permit. If the arms do not 
lock readily the blades should be readjusted till they do. 
The locking must never be forced. Guard against pinching 
the skin or hair of the vulva in the lock of the instrument. 
Before making traction re-examine to see that the blades are 
correctly applied. 

Extraction. The handles are held lightly near the lock, 
with care to avoid compression of the head. 

The traction should be intermittent — a pull and a pause. 
The pull should coincide with a pain, if possible, and should 
last one minute. Reinforce traction with expressio foetus, 
applied by an assistant. In the intervals of traction the in- 
strument should be unlocked to relieve pressure on the head. 

Guard against Slipping Readjust the blades to a better 
grasp if they begin to slip. When the head cannot be 




Method of applying the traction force in axis of pelvis in operation on low bed. 

(Pajot.) 



caught primarily over the parietal eminences it may be 
necessary to change the grasp, as the head rotates in course 



OBSTETRIC SURGERY. 



323 



of descent. The force used must be such only as can be 
applied with the arms without bracing the feet. 

Line of Traction. The force must act in the direction of 
the birth-canal. In order to this, at the brim the handles 
are grasped with one hand, and with the other downward 
pressure is applied upon the shanks near the lock (Pajot). 
(Figs. 68 and 69.) With forceps of moderate pelvic curve 
a straight pull on the handles answers after the head reaches 
the pelvic floor. 

Fig. 69. 




Showing Pajot's manoeuvre for axis traction with plain forceps ; operation on 

high table. 



Until the head rests on the pelvic floor the direction is 
practically a straight line, parallel with the posterior sur- 
face of the symphysis pubis. Then the line of traction turns 
almost directly forward. The handles are swept upward 
until the anterior edges of the blades hug the ischio-pubic 
rami as closely as practicable without crushing the inter- 
vening soft parts. 

Force. The force required varies from ten to fifty pounds. 
Time is an important element in a safe forceps extraction. 



324 ESSENTIALS OF OBSTETRICS. 

It is a familiar principle of mechanics that the resistance of 
a moving body increases as the square of the rate of motion. 
This is not altogether inapplicable in the forceps operation. 
At least a half hour should be taken for a low forceps de- 
livery, more for a high operation. 

Perineal Stage. The instrument may or may not be re- 
moved during the passage of the head over the perineum. 
Beginners, at least, will succeed best without forceps. 

A half hour or more should be given to the perineal 
stage of delivery except when prompt extraction is de- 
manded in the interest of the child. 

Removal of the Forceps. When the blades are removed 
before the birth of the head the right blade 1 is removed 
first, carrying the handle well up over the opposite groin 
and protecting the soft parts with two fingers placed between 
the ischio-pubic ramus and the anterior edge of the blade ; 
the left is then withdrawn in corresponding manner. 

Occipito-posterior Positions. Here the forceps operation 
is a dangerous and difficult one. If the head is firmly 
impacted forceps is contra-indicated, and symphysiotomy 
should be considered. Persistent posterior positions of the 
occiput imply imperfect flexion. The beginning traction 
should therefore be made in a somewhat forward direction, 
with a view to increasing flexion. Rotation, while it 
may be favored, must not be forced. 

Face Presentation. In mento-posterior positions, as a 
rule, the use of forceps is not permissible. In arrested 
anterior positions of the face the traction should be directed 
forward to carry the chin under the pubic arch. 

Breech Presentation. Here the blades are applied over 
the trochanters, or one over the posterior surface of one 
thigh, the other over the opposite ilium and the sacrum, 

1 That on the mother's right. 



OBSTETRIC SURGERY. 325 

Application over the iliac crests is unsafe owing to the 
danger of injuring the child's abdomen by the pressure of 
the blades and even of serious injury to the bones. 

AXIS-TRACTION FORCEPS. 

The Instrument. The axis-traction forceps is provided 
with a pair of traction rods, one attached to the heel of each 
blade by a movable joint at their lower ends. The trac- 
tion rods are bent backward and attached by a universal 
joint to a cross-bar, which serves as a traction handle. (Fig. 
70.) By this construction the pull is directly in line with 

Fig. 70. 




Author's axis-traction forceps. 



the axis of the blades, and, therefore, with the axis of the 
passages. (Fig. 71.) 

Advantage. It reduces the traction force to a minimum 
by applying it in the line of descent and hence to the best 
mechanical advantage. It permits the normal movements 
of flexion and rotation as the head descends. 

Position of Patient. If the patient lies on a table the 
position is the dorsal recumbent ; on a low bed, the latero- 
prone is better. 

15 



326 



ESSENTIALS OF OBSTETRICS. 



Application. The blades are adjusted to light pressure, 
and held with the fixation screw. 



Fig. 71. 




Axis-traction forceps. A B, axis of blades. 

Traction. The pull is applied at the traction-bar. The 
handle of the forceps serves to indicate the line of traction, 
which is regulated by keeping the traction rods nearly 
parallel with the forceps handles. The traction force should 
seldom, if ever, exceed fifty pounds. As a rule, ordinary 
forceps should be substituted after the head has reached 
the pelvic floor. 

VERSION. 

Version consists in partial or complete inversion of the 
foetal ovoid by manual interference, substituting the cephalic 
or pelvic pole for a less favorable presentation. 

Cephalic version causes the head to present. Podalic 
version causes the feet to present. 

The term pelvic version applies when any of the elements 



OBSTETRIC SURGERY, 327 

of the pelvic pole of the foetus is substituted for some other 
presenting part. In its restricted sense it refers to a version 
which causes the breech to present, an operation which is 
seldom or never called for. 

Indications, (a.) For cephalic version are : Breech pres- 
entation, if the conditions are favorable (external method 
before labor), shoulder presentation. 

(b.) For podalic version are : Flattening of the pelvis not 
below 9.5 cm. (3f inches) c. v. ; and equivalent contraction 
of other forms ; placenta prsevia, simple cases excepted ; 
prolapsed funis not otherwise manageable ; most face cases 
before engagement ; irreducible occipito-posterior positions ; 
most complex presentations ; shoulder presentation when 
cephalic version is impossible ; certain emergencies demand- 
ing rapid delivery, head not engaged ; the dead child may 
generally be delivered by podalic version in contraction to 
7.5 cm. (3 inches) c. v. 

Contra-indications to version are firm engagement of 
the head; high position of the retraction ring; persistent 
contraction of the uterus, especially in dry labors. Internal 
version should be undertaken only after the os is fully 
dilated, or nearly so, and dilatable. The absence of liquor 
amnii, while not a contra-indication, greatly embarrasses the 
operation. 

Dangers of Version. To the mother. In external and 
in bipolar version the dangers are usually insignificant. 
Rupture of the uterus has occurred in difficult cases. 

In internal version there is danger of uterine rupture and 
increased risk of sepsis. Rapid extraction following ver- 
sion increases the danger of laceration and also of shock. 

To the child. The dangers to the child in internal ver- 
sion are possible fracture of the bones, compression of the 
spine, and the usual risks of ordinary breech-birth. 



328 ESSENTIALS OF OBSTETRICS. 

Operation. Most essential is an exact knowledge of the 
capacity of the pelvis, the size of the foetal head, and the 
presentation and position of the foetus. Make a thorough 
examination after the patient is anaesthetized. For internal 
version the passages must be fully dilated or easily dilatable. 
If immediate delivery is intended the usual preparations for 
a breech extraction should be made. The operation is best 
conducted on a table. Two assistants beside the anaesthetist 
should be had if possible. 

A. External Version. 

External version is applicable, as a rule, only before 
labor. It is permissible when it can be done without 
violence. 

Method. Placing the hands upon the abdomen, one 
over each foetal pole, the poles are pushed in opposite direc- 
tions. The manipulation is practised between the pains. 
During the pains the foetus is held to prevent reversion to 
the former presentation. Finally, after the version is com- 
plete, a binder and lateral compresses are applied over the 
abdomen to prevent recurrence of the malpresentation. 

B. Bipolar Version. 

Advantages of the bipolar over internal version are : A 
minimum of traumatism and shock ; less danger of infection. 
The fact that it may be done early in the first stage of labor 
is a distinct gain in placenta praevia. The bipolar should 
be preferred to the internal method when practicable. 

Method. As a rule anaesthesia is necessary. The 
bladder and rectum must be empty. The patient is placed 
in the dorsal recumbent position. The manipulation is con- 
ducted between the pains. A strict asepsis is imperative. 



OBSTETRIC SUBGEBY. 



329 



One or two fingers of one hand are passed through the cer- 
vix, and the other hand is placed over the opposite foetal 
pole externally. With the external hand the breech is 
pushed toward the side on which the feet lie. (Fig. 72.) 



Fig. 72. 




First stage of bipolar version. Elevation of the head and depression of the 
breech. (After Barnes.) 

With the internal hand the head is tossed out of the excava- 
tion into that iliac fossa toward which the occiput points 
(Fig. 73) ; the trunk is pushed along in the same direction, 
inch by inch, till a knee presents. (Fig. 74.) The knee is 
drawn down and the foot extracted. (Fig. 75.) The other 
foot may also be brought down if easily accessible. The 



330 ESSENTIALS OF OBSTETRICS. 

Fig. 73. 




Second stage of bipolar version. Elevation of the shoulder and depression 
of the breech. (After Barnes.) 



Fig. 74. 




Third stage of bipolar version. Seizure of the knee and partial elevation 
of the head. (After Barnes.) 



OBSTETRIC SURGERY. 



331 



labor is thenceforth to be conducted as in spontaneous breech 
cases. The operator should cease manipulation during ute- 
rine contractions. 

A bipolar manipulation is applicable in cephalic version 

also. 

Fig. 75. 




Fourth stage of bipolar version. Drawing down of the legs and completion 
of version. (After Barnes.) 



C. Internal Version. 

Method. The patient is placed in the dorsal recumbent 
position under an anaesthetic. In difficult cases the knee- 
chest or the Trendelenburg position may be utilized. The 
clothing of the operator is covered with a sheet or operating 
gown. The passages, their approaches, and the operator's 
hands must be surgically clean. One hand is passed into 



332 ESSENTIALS OF OBSTETRICS. 

the uterus over the abdomen of the child, palmar surface 
toward the child. Either foot or both feet are seized and 
the foetal ovoid is inverted by traction. If a hand is within 
reach it is snared and held down sufficiently to prevent ex- 
tension. A prolapsed arm must be pushed above the brim. 
The other hand of the operator may be used externally to 
steady the fundus or to assist the rotation of the child by 
pushing up the cephalic pole. The operator relaxes the hand 
and desists from manipulation during the pains. To pre- 
vent cramping of the hand the least possible muscular effort 
must be used. 

The completion of the birth is managed as in ordinary 
breech extractions. 



OBSTETRIC SURGERY OF THE ABDOMEN. 

CESAREAN SECTION: CCELIO-HYSTEROTOMY. 

Definition. Cesarean section is an operation for extrac- 
tion of the child by section of the abdominal and the uterine 
Avails. 

Historical Note. This operation antedates the Christian 
era. The earlier Csesarean sections, however, were post- 
mortem operations done a few minutes after the death of 
the mother to save the child. The earliest Caesarean section 
upon the living subject of which we have any knowledge 
was performed in the year 1500. 

Capabilities of the Modern Operation. Timely oper- 
ations under the modern (Sanger) method should save not 
less than 92 to 95 per cent, of the mothers, and the chances 
for the children should be as good as in spontaneous births. 
The maternal mortality is very great in operations delayed 
till the woman is exhausted by long labor and by attempts 



OBSTETRIC SURGERY. 333 

at delivery by other means, especially if exhaustion is com- 
plicated by sepsis. The foetal death-rate also is increased 
in late operations. 

Indications. With a living and viable foetus, the woman 
in operable condition, the head being of average size, Cesa- 
rean section is indicated in flattened pelves, when the con- 
jugate is below 7 cm. (2| inches), and in other forms of 
contraction in which there is equivalent disproportion 
between the head and the pelvic space ; generally with dead 
foetus, when the conjugate is below 6.3 cm. (2J inches), 
and in cancer of the cervix, when delivery per vias natur- 
ales is impracticable. 

In lesser grades of obstruction Cesarean section may 
sometimes be chosen in preference to its alternatives if all 
conditions are favorable. When the degree of obstruction 
is such that the delivery of a living child is impossible by 
other means, the indication is said to be absolute. When 
other operative methods are practicable in a given case, and 
the Cesarean operation is elected, it is said to be done on 
the relative indication. 

The preferred time for operating is a few days before the 
expected date of labor. Operation at an appointed time 
before labor permits better preparation, the patient's con- 
dition is better, the uterus retracts as well as in operation 
during labor, and drainage is all-sufficient or can be made 
so. There is a distinct advantage in operating before rup- 
ture of membranes since there is less traumatism, the child 
is more certainly viable and extraction is easier. 

Preparatory Measures. If necessary, the patient's 
strength should be reinforced by tonics and hygienic 
measures. The bowels are thoroughly opened the day 
before operating. 

The bladder should be emptied and the rectum washed 

15* 



334 ESSENTIALS OF OBSTETRICS. 

out immediately before the operation. The operator as- 
sures himself that there is no loop of intestine between 
the uterus and the abdominal walls, beneath the field of 
incision. Should a coil of intestine be found here it is 
pushed above the fundus. 

Instruments should be sterilized by boiling for ten min- 
utes in a 1^- per cent, solution of washing-soda. 

The hands and arms of the operator and assistants should 
be sterilized and their clothing covered with operating gowns 
which have been steamed for a half-hour immediately before 
using. Operator, assistants, and nurses wear muslin caps 
fresh from the steam-chamber to cover the hair. 

The abdomen is prepared as follows : On the evening 
before operation, after a total bath and a change of linen — 

Cover the entire abdomen with a green soap dressing for 
three hours ; 

Scrub with a soft, sterile brush, green soap and hot 
water ; 

Shave the entire surface with a sterile razor ; 

Re-scrub ; 

Rinse with sterilized water. 

Wash with alcohol, using a pledget of aseptic cotton ; 

Scrub with the mercurial solution (1 : 2000), using a 
freshly sterilized brush ; 

Cover all with a compress well wet with the mercurial 
solution, and held with a binder. 

On the morning of operation the entire field is covered 
with a compress wet with Labarraque's solution, which is 
removed just before the first incision. 

In emergency cases the antisepsis must be as complete as 
the limited time allows. 

The temperature of the room should be 75° to 80° F. 

The patient is placed in the horizontal position and the 



OBSTETRIC SURGERY. 335 

body and extremities are wrapped warmly with clean flannels, 
except the operative field. The clothing about the field of 
operation is covered with dry cloths or towels sterilized by 
steaming for a half-hour, and finally a sheet fresh from the 
steam-chamber and provided with an opening to expose the 
field of operation is spread over the patient and top of table. 

Assistants. The first assistant stands on the left of the 
patient, opposite the operator. Another gives the anaes- 
thetic. A nurse or third assistant takes charge of the 
steam sterilizer and the instruments. Another assistant 
stands ready to receive the child. 

Instruments. Scalpel ; straight scissors ; two thumb-for- 
ceps ; six to twelve catch-forceps ; haemostatic-forceps; needle- 
holder and needles; long catch-forceps (Keith) for holding 
sponge compresses; a large, thin- walled rubber tube, 1.25 
metre (about four feet) long, as a constrictor for the neck 
of the uterus ; a steam-sterilizer for sterilizing cheese-cloths, 
towels, etc. ; twelve medium-sized silk sutures for the deep 
uterine suture ; twelve fine silk sutures for the superficial 
uterine suture ; twelve silkworm-gut sutures of medium size 
for deep abdominal sutures ; a plain 00 catgut for the peri- 
toneum ; a chromated catgut for closing the fascia ; a 
plain catgut of the same size for the skin ; several dozen 
gauze compresses to be used for sponging. 

Summary of the Conditions of Success. The elective 
operation ; a perfectly aseptic technique; deep uterine sutures, 
three to the inch ; superficial or half-deep between the deep 
sutures ; maintenance of the natural temperature of the 
abdominal contents ; the least possible injury to peritoneal 
surfaces ; operation within thirty to forty minutes. 

Steps of the Operation: 1. Median incision of the 
abdominal wall ; 

2. Application of the uterine constrictor ; 



336 ESSENTIALS OF OBSTETRICS. 

3. Median incision of the uterus ; 

4. Extraction of the child and placenta ; 

5. Closure of the wounds and application of the abdom- 
inal dressing. 

Technique of the Operation. An assistant holds the 
uterus in central position. The skin incision extends from 
a little above the navel to a point an inch above the sym- 
physis, uncovering the linea alba. The tendon is divided, 
exposing the subperitoneal fat. Should the incision miss the 
linea alba and enter one of the recti muscles, separate the 
muscular bundles with the scalpel handle, pick up the fascial 
layers beneath with the forceps and divide them down to the 
retro-peritoneal fat. Bleeding vessels are held by catch- 
forceps or ligated before opening the peritoneum. The fat 
is pushed aside and the peritoneum lifted with thumb-for- 
ceps and nicked with the scalpel or scissors close to the 
forceps, and the incision extended to nearly the full length 
of the first incision on the finger as a guide. An assistant 
injects into the thigh hypodermically 5ss of fluid ergot. A 
loop of the constrictor is passed over the fundus and adjusted 
around the cervix ; it is tightened only as necessary to con- 
trol hemorrhage ; or the constrictor may be dispensed with, 
the assistant encircling the lower segment of the uterus with 
his hands and using compression as required for the preven- 
tion of bleeding. A short median incision is made in the 
uterine wall well above the retraction ring, avoiding the 
membranes if still unbroken. This is lengthened upward 
with the fingers or scissors to a point short of the fundus. 
The length of the uterine incision should not exceed 12 cm. 
(5 inches). The hand is thrust through the membranes and 
the child extracted by the head or the feet. In case of 
anterior implantation of the placenta, it is separated at one 
edge and pushed aside, or the hand may be passed directly 



OBSTETRIC SURGERY. 337 

through it. The cord is clamped at two points with catch- 
forceps, cut between them, and the child passed to an as- 
sistant. 

As the uterus slips out of the abdomen the intestines are 
kept back, if necessary, with hot sterilized towels placed 
over the upper part of the incision. The coverings help 
also to protect the peritoneum from soiling. The uterus is 
wrapped in hot moist cloths. The placenta, if not sponta- 
neously separated, is peeled off by clawing with the fingers 
of one hand. If the cervix is not sufficiently open for drain- 
age it is dilated instrumentally or manually. 

Irrigating or mopping the uterine cavity is unnecessary. 
Asepsis is promoted by leaving it as nearly as possible un- 
touched. Irritating the peritoneum by handling, needless 
sponging, or contact of chemical antiseptics should be avoided. 

The uterine wound is closed with deep silk sutures at 
intervals of 1 cm. (about J inch). They are entered 1.3 
cm. (J inch) from the incision and passed obliquely inward, 
falling short of the decidua. The peritoneal coat of the 
uterus is generally closed with sutures of fine silk or catgut 
between the deep sutures dipping into the muscular coat. 
Remove the constrictor and secure retraction of the uterus, 
if necessary, by manipulating it through a hot towel or by 
faradism. Pull down the omentum over the uterus. If 
liquor amnii or much blood has escaped into the peritoneal 
cavity, it should be removed by gentle sponging. When 
there has been much blood-loss a quart or two of warm 
sterilized 0.7 per cent, salt solution may be left in the peri- 
toneum. The parietal peritoneum is closed with a plain 
running catgut suture (00). Interrupted silkworm-gut 
sutures are then passed at intervals of 2 cm. (about f inch) 
through all but the peritoneum from within outward. The 
fascia is brought together with a running chromated catgut 



338 ESSENTIALS OF OBSTETRICS. 

suture (0), and the skin with a running cutaneous or a sub- 
cuticular suture of plain catgut. The silkworm-gut sutures 
are now tied. Fluid extract of ergot 5ss is given hypoder- 
mically. The abdominal wound is dressed with several 
thicknesses of dry sterilized cheese-cloth held in place with 
an abdominal binder. 

After-treatment. To promote reaction the bed is 
warmed with hot-water bags, and the patient's head is 
wrapped in flannel ; an injection of whiskey or coffee and 
hot water may be given by the rectum if required. An 
eighth-grain of morphine or twice as much codein may be 
given subcutaneously in case of much pain or restlessness. 
The bladder should be emptied every eight hours, but the 
catheter should be withheld if possible. The child is put 
to breast as in normal cases. Give a tablespoonful of 
hot water every half-hour to quench thirst. Feeding is 
begun with light liquid food as soon as it can be retained, 
within twelve to twenty-four hours usually. The bowels 
are opened with salines on the second or third day after 
operation, sooner should evidence of infection appear. 
The silkworm-gut sutures are removed by the fourteenth 
day. 

The patient can usually leave the bed at the end of three 
weeks. A firm abdominal binder or supporter should be 
worn for two or three weeks after operation. 

Post-mortem Caesarean Section. In case of sudden 
death of the mother in the last month of gestation, the child 
may usually be delivered alive by abdominal section, if ex- 
tracted within five minutes after the mother's death. It is 
stated on good authority that in exceptional instances the 
child may survive in utero for several hours after death of 
the mother. 



OBSTETRIC SUB GEE Y. 339 

PORRO OPERATION: CCELIO-HYSTERECTOMY. 

Definition. A Cesarean section, supplemented by supra- 
vaginal amputation of the uterus and removal of the tubes 
and ovaries. 

The operation is named after Edward Porro, of Pavia. 
Italy, who was first to perform it. in 1876. The results in 
equally favorable conditions should not fall much short of 
those attained in simple Cesarean section. 

Indications are myomata of the uterus : marked puerperal 
osteomalacia : uterine sepsis ; uncontrollable hemorrhage 
after Cesarean section: vaginal atresia obstructing drainage. 

Steps of the Operation. Abdominal incision, as in 
Cesarean section : eventration of the uterus ; constriction 
of the cervix with a finger-thick rubber tube, passing loop 
over the fundus, the ovaries and tubes being held up : 
packing hot cloths about the cervix to keep blood and liquor 
amnii from soiling the peritoneum : incision of the uterus 
and extraction of child and placenta : transfixion of the 
cervix by passing two or three knitting-needles or hat-pins 
at different angles through the constricting rubber-tube and 
the cervix : amputation of the uterus '2 cm. (f inch) above 
the constrictor: ligation of the uterine arteries in the stump 
or at the sides of it ; stitching the entire circumference of 
the stump in the lower angle with the free surfaces of peri- 
toneum in contact : suture of the abdominal wound : mummi- 
fication of stump with perchloride of iron solution: abdomi- 
nal dressings as in C cesarean section. 

This operation is practically superseded by the usual 
modern method of supravaginal amputation. The tech- 
nique, after the uterus is evacuated, does not differ from 
that of abdominal hysterectomy as done for fibroids. The 
after-treatment, too, is the same. 



340 ESSENTIALS OF OBSTETRICS. 

SYMPHYSIOTOMY. 

Historical Note. Division of the pubic joint for the 
purpose of facilitating delivery in narrow pelves was first 
done on the living woman in France bv Jean Rene Sigault 
in 1777. Meeting partial acceptance for a time, the opera- 
tion, after a half century, had become practically obsolete. 
Revived by Morisani, of Xaples, Italy, in 18G6, it was taken 
up in the country of its birth by Pinard early in 1892. 
His success and advocacy led to its immediate adoption 
throughout the world. 

Results. The maternal mortality of the modern opera- 
tion is about 14 per cent. Of the children little less than 
one-third have been lost. Restoration of the symphysis, as 
a rule, is complete. Possible complications of the operation 
are lacerations of the anterior soft parts, including the 
urethra and bladder, and hemorrhage, more rarely suppura- 
tion of the symphysis and injury to the sacro-iliac joints. 

Space Gained. The maximum pubic separation permis- 
sible, according to most authorities, is 7 cm. (2 J inches) ; 
with an interpubic opening of that extent the conjugata 
vera gains a little more than 1.3 cm. (J inch). The trans- 
verse at the brim gains once and a half, the oblique about 
twice as much as the conjugate does. The parietal boss 
projects into the interpubic space, and this is equivalent to 
a slight additional increase in the conjugate. 

Indications. Simple flattening of the pelvis not below 
7 cm. (2f inches) in the conjugate, or equivalent dispro- 
portion from other causes; irreducible occipito-posterior 
positions ; impacted mento-posterior face cases, and irre- 
ducible brow presentation. The operation is contra-indicated 
in ankylosis of one or both sacro-iliac joints. The foetus 
must be living and viable. 



OBSTETRIC SURGERY. 



341 



Method of Operating. The patient lies in the dorsal 
position, with the thighs strongly flexed and the knees held 
apart, under an anaesthetic. The antiseptic preparation of 



Fig. 76. 




Incision in symphysiotomy by the open method ; dividing the suspensory 
ligament of the clitoris. 



the abdomen is the same as for cceliotomy. The vulva and 
the vagina are prepared with the same care as the abdomen. 



342 



ESSENTIALS OF OBSTETRICS. 



The cervix must be fully dilated. A metallic catheter is 
passed into the bladder by an assistant and pressed back- 
ward and to one side. This helps to protect the urethra 
and vesical neck from injury, and, at the same time, keeps 
the bladder empty. The abdominal incision may be long 
or short. The long incision begins an inch above the top 
of the symphysis, and is carried down over the anterior 

Fig. 77. 




Showing clitoris drawn down after division of its suspensory ligament, and the 
pubic arch laid hare. 



surface of the joint — the open method ; the short incision 
is from one to three inches in length, and terminates below 



OBSTETRIC SURGERY. 343 

at the top of the symphysis — the subcutaneous method. 
The advantage of the former is that the steps are conducted 
under direct inspection ; it is claimed for the latter that the 
wound is less exposed to infection by the lochia. The open 
method is recommended. 

The division of the joint in the open method is con- 
ducted as follows : The incision exposes the entire length 
of the joint, extends an inch above it, and opens the 
space between the recti muscles. The clitoris is drawn 
down with a sharp hook caught just above it, its sus- 
pensory ligament cut (Fig. 76), and the bony margin of 
the pubic arch laid bare. (Fig. 77.) The retro-pubic 
structures are pushed back with the finger passed down 
behind the symphysis, a broad, strongly curved director is 
passed immediately behind the joint from below upward or 
from above downward. The clitoris and other vascular 
structures at the lower end of the symphysis are thus held 
back during the division of the joint. This prevents hemor- 
rhage, which is otherwise sometimes a serious complication. 
The joint is located by finding the notch at the top between 
the pubic bones or by forcibly flexing and extending one 
lower extremity while the other is held stationary. The 
symphysis is then divided with a strong, slightly curved, 
blunt-pointed bistoury from behind forward or from before 
backward. The bones are cautiously separated and held 
apart to the extent of 7 cm. (2f inches), the lateral halves 
of the pelvis being firmly supported by the assistants to 
prevent further separation as the head is forced down. 

In the subcutaneous method the incision is from 2.5 
to 7.5 cm. (1 to 3 inches) in length, according to the thick- 
ness of the abdominal walls, and terminates below at the 
top of the symphysis. It is carried down between the 
recti muscles. The finger is passed behind the symphysis, 



344 ESSENTIALS OF OBSTETRICS. 

and the joint divided by the bistoury from behind forward 
and from above downward, the finger serving as a guard and 
a guide. Venous hemorrhage, which is sometimes profuse, 
is controlled by pressure by packing the wound and, if 
necessary, the vagina with sterilized gauze or by haemo- 
static suture. The short incision may be extended should 
it become necessary for the control of hemorrhage or by 
reason of other complications. When, owing to bony anky- 
losis or to the sinuous course of the symphysis, division 
with the knife is impossible, the joint may be opened with 
a metacarpal or a chain saw. The child is extracted by 
forceps if it is not promptly expelled by the natural forces. 
Episiotomy should be done, if necessary, to prevent lacera- 
tion of the anterior soft parts at the vaginal outlet. Great 
care must be used during delivery to prevent laceration of 
the anterior vaginal wall. After delivery of child and 
placenta, the bones are brought firmly together, the urethra 
and the vesical neck being meantime held backward to avoid 
pinching between the bones. The soft parts are closed 
with silkworm-gut sutures, which, in the open method of 
operating, should include the fibrous structures in front of 
the joint. Two or three strands of silkworm-gut may be 
carried down from behind the joint as a drain. This is 
removed in twenty-four hours. The pelvis is immobilized 
by means of two or three strips of rubber adhesive-plaster, 
reaching obliquely from one side of the pelvis to the other 
above the wound, and over these a firm binder. The 
patient lies, moreover, during convalescence in a hammock- 
bed (Ayers), or on two firm cushions which support the 
body by the lateral halves of the pelvis. A canvas binder 
provided with straps and buckles for fastening makes a firm 
and easily adjustable support. An ounce or two of iodoform 
and boric acid, 1 : 8, may be left in the vagina. 



OBSTETRIC SURGERY. 345 

After-treatment. For three or four weeks the patient 
should lie on the back with the limbs outstretched. The 
urine may need to be drawn off with a catheter for the first 
two or three days after operation. 

The binder is changed as often as soiled. The sutures 
are removed by the eighth or tenth day. The patient is 
kept in bed for four weeks. The binder remains six weeks. 

EMBRYOTOMY. 

Embryotomy is the general term for all obstetric oper- 
ations employed to facilitate delivery through the natural 
passages by lessening the size of the foetus. 

Indications are hydrocephalus too large for safe extrac- 
tion without perforating and not manageable by aspiration 
of the cranial cavity ; obstructed labor with a dead or non- 
viable foetus or a foetal monstrosity, conjugate exceeding 2 J 
inches ; and impacted shoulder or face presentation if the 
child is dead. 

It is very rarely that embryotomy will be justifiable on 
the living and viable child. The sacrificial operation must 
be considered as an alternative of Cesarean section or 
symphysiotomy when the condition of the mother is un- 
favorable for the latter operations, and especially if she 
elects the former with a full knowledge of the facts. 

CRANIOTOMY. 

Definition. An operation for the comminution and re- 
moval of all or a portion of the cranial bones to facilitate 
delivery. 

Steps. 1. Perforation. The field of operation should 
be cleansed and disinfected and the woman placed on the 



346 ESSENTIALS OF OBSTETRICS. 

table, in the obstetric position and under an anaesthetic. 
All but the operation field is covered with an aseptic sheet. 
The instrument may be a Smellie's scissors or Naegele's 
perforator (Fig, 78), preferably the trephine. In emer- 
gency a long, sharp-pointed surgical scissors will serve the 
purpose. The bladder and rectum should be empty. An 
assistant steadies the head by grasping it above the brim 
with the hands placed over the abdome n. 

Fig. 78. 



Naegele's perforator. 

The point of the perforator is passed against the head, 
perpendicularly to the surface of contact, just behind the 
pubic bones, the finger of one hand serving as a guide and 
guard. Except when the trephine is used the puncture is 
best made through a suture or fontanelle. 

The point is fixed in the tissues by a screw-like motion, 
and perforation is then effected by a similar motion. 

The blades are separated in different directions to enlarge 
the opening. 

The most approved method of perforating is with the 
trephine. It removes a button of bone, leaving a perma- 
nent opening through which the cranial contents can readily 
be evacuated. 

The after-coming head may be perforated through a skin 
incision made at the base of the neck posteriorly ; the per- 
forator is passed subcutaneously. 

The brain is broken up with the perforator and washed 



OBSTETRIC SURGERY. 347 

out with a stream of sterilized water forcibly injected with 
a Davidson's syringe. 

2. Comminution. With the craniotomy forceps passed 
within the scalp, the cranial bones are seized, one by one, 
and dislodged by rotating the forceps about its long axis 
and then removed. In moderate obstruction the head may 
be crushed and extracted with a cephalotribe. 

In the higher grades of pelvic contraction the cranial 
base, as well as the vault, has been broken up. Tarnier's 
basiotribe was devised for this purpose. Between its blades 
is a screw perforator, which is made to perforate the head, 
while the blades crush it. With the resources of modern 
obstetric surgery basiotripsy is scarcely justifiable. 

3. Extraction is effected with the craniotomy forceps or, 
when space permits, with the cephalotribe, guarding care- 
fully against laceration of the passages by projecting spicula 
of bone. If craniotomy forceps is used, one blade is passed 
within and one without the cranial cavity. In extreme 
narrowing the cranial base is best delivered edgewise by 
drawing down the chin. 

CEPHALOTRIPSY. 

Cephalotripsy is an operation for reducing the size of the 
head by crushing the cranial vault. The best cephalotribe 
is Lusk's. (Fig. 79.) 

The method of application does not differ from that of 
the obstetric forceps. An assistant crowds the head firmly 
into the excavation if it is not already engaged. The head 
is perforated and the cephalotribe is applied with care to 
secure a good grasp. 

The skull is then slowly crushed by turning a powerful 
screw at the handles. The head is brought down with the 



348 ESSENTIALS OF OBSTETRICS. 

cephalotribe used as a tractor. Since the cranial vault is 
expanded in one direction as it is crushed in the opposite, 
care must be used to guard against laceration of the pas- 



Lusk's cephalotribe. 

sages by projecting spicula of bone. The elongated diam- 
eter of the head must be kept in the long diameter of the 
pelvis. 

Cephalotripsy is practicable only in moderate contraction. 

EVISCERATION. 

This term applies to all operations for reducing the size 
of the trunk by removal of its viscera. The operation is 
limited almost wholly to cases of impacted shoulder in 
which decapitation would be difficult or impossible. 

Perforation of the trunk may be done with a craniotomy 
perforator, or through the bony coverings of the chest with 
the trephine. The viscera are then broken up with the 
perforator and removed with craniotomy forceps, with stout 
dressing-forceps, or with the fingers. The bony walls, if 
necessary, may be cut away piecemeal with strong scissors. 

Sometimes the trunk is divided into sections with a chain, 
saw, or stout blunt scissors, and delivered piecemeal. The 
head is then crushed and extracted with the cephalotribe. 



OBSTETRIC SURGERY. 



349 



DECAPITATION. 

Methods. 1. Blunt hook and scisso?°s. While an 
assistant draws the neck firmly down with a blunt hook 
or a strong tape passed around the neck, the neck is 
gradually severed with blunt-pointed scissors guarded by 
two fingers of the other hand. 

Fig. 80. 





B rami's hook. 



2. Braun's hook is a convenient and safe instrument for 
decapitation. (Fig. 80.) The hook is passed flatwise on 
the hand as a guide. It is carried up between the head 
and the pubic bones till it can be hooked over the neck. 

16 



350 ESSENTIALS OF OBSTETRICS. 

The neck is then firmly engaged in the hook by traction. 
Under a to-and-fro movement of the handle the neck is 
readily severed. 

3. Ecraseur. A tape is passed around the neck as fol- 
lows : It is first well oiled and knotted at one end ; the 
knot is pushed up over one side of the neck with the fingers 
of one hand, the fingers of the other hand catching it and 
pulling it down on the other side. Another method of car- 
rying the tape into place is with an English bougie prop- 
erly curved and armed with a stylet. The chain of the 
ecraseur is attached to the tape and drawn into place. The 
neck is then cut through by tightening the chain. 

A wire ecraseur armed with piano-wire or common 
picture-wire may be used for the purpose, or a chain saw 
may be substituted for the ecraseur. 

Extraction. After decapitation the head is pushed up 
and the trunk delivered; then the head is extracted, chin 
first. Two fingers of one hand are hooked in the inferior 
maxilla and the head crowded through the pelvis by supra- 
pubic pressure with the other hand or delivered with forceps 
or cephalotribe. In a narrow pelvis it may be necessary to 
crush the head before it can be delivered. Perforation may 
be done in the grasp of the cephalotribe and the cranial con- 
tents then be broken up and removed in the usual manner. 
Care must be taken lest the uterus be ruptured in these 
manipulations or the passages be lacerated by projecting 
bone-fragments. 



INDEX 



ABDOMEX, obstetric, surgery of, 
332 
pigmentation of, in pregnancy, 
72 
Abdominal binder, 158 

enlargement from other causes 
than pregnancy, 81 
in pregnancy, 72, 73 
examination for presentation and 

position of foetus, 123 
signs of pregnancy, 72 
Abortion, 205 
causes of, 205 
diagnosis of, 206 
incomplete, 210 
induction of, 312 
indications for induction of, 312 
methods of, 313 
treatment of, 207 
Accidental hemorrhage, 278 
causes of, 279 
diagnosis of, 279 
treatment of, 280 
yarieties of, 278 
Adherent placenta, remoyal of, 315 
After pains, 163 

treatment of, 165 
Allantois, 51 
Amnion, 19 

anomalies of, 191 
Anaemia, acute, treatment of, 273- 
278 
in pregnancy, 222 
Anaesthesia in labor, 111 

method of, 116 
Anomalies of foetal development as 

causes of dystocia, 260 
Ante-partum examination, 122 
hemorrhage, 273 



Antisepsis in labor, 136 

in puerperium, 166 
Areola? of breasts, changes in pri- 
mary during pregnancy, 70 
secondary, 71 
Armamentarium, obstetric, 134 
Artificial feeding of newborn child, 

177 
Asphyxia neonatorum, 172 
treatment of, 172 
Byrd's method, 173 
direct insufflation, 173 
faradism, 171 
Laborde's method, 171 
Schultze's method, 173 
Sylvester's method, 173 
Atresia, vaginal, as a cause of 
dystocia, 237 
vulvar, as a cause of dystocia, 
237 



BAG of waters, 111 
Ballottement, internal, as sign 
of pregnancy, 81 
Bartholin, gland of, 19 
Binder, abdominal, 158 
Bladder, evacuation of, after labor, 

165 
Blastoderm, 48 
Blastodermic vesicle, 48 
Bowel movements, regulation of, in 

puerperium, 165 
Breech presentation, 217 
causes of, 218 
diagnosis of, 249 
mechanism of, 248 
prognosis of, 250 
treatment of, 250 



352 



INDEX. 



Brow presentation, 246 

treatment of, 247 
Bulbi vestibuli, 18 
Bulbo-cavernosus muscle, 103 



/CESAREAN section, 332 
\J after-treatment of, 338 
capabilities of, 332 
indications for, 333 
post-mortem, 338 
preparatory measures for, 333 
steps of operation, 335 
technique of, 336 
Caput succedaneum, 119, 172 
Care of the breasts and nipples 

during lactation, 169 
Cardiac disease as a complication 

of labor, 290 
Caruncular myrtiformes, 20 
Catheter, use of, 167 
Cephalhematoma of newborn 

child, 187 
Cephalotripsy, 347 
Cervix, cancer of, as a cause of 
dystocia, 238 
rigidity of, as a cause of dystocia, 

237 
uteri purplish color of, in preg- 
nancy, 77 
softening, in pregnancy, 77 
Cervical lacerations, 150 
method of suture, 150 
Child, care of premature, 311 
condition of, at birth, 170 
newborn, bathing of, 174 

bloody genital discharge in, 

192 
cephalhematoma in, 187 
circulation of, 170 
clothing of, 175 
colic in, 186 
constipation in, 184 
diarrhoea in, 186 
disorders of, 184 
genito-urinary organs of, 171 
icterus in, 188 
indigestion in, 185 
intertrigo in, 187 
management of, 172 
mastitis in, 192 



Child, newborn, navel dressing of, 
175 
nursing, 176 

contraindications to, 170 
ophthalmia in, 189 
preputial adhesion in, 186 
respiration of, 170 
skin of, 171 
tetanus in, 191 
thrush in, 186 
umbilical hemorrhage in, 191 

infection in, 190 
weaning, 177 
weight of, 170 
wet-nursing, 176 
Choc foetal, 75 
Chorial villi, 53 
Chorion, 52 

cystic degeneration, 196 
diseases of, 196 
frondosum, 54 
laeve, 54 

vesicular mole, 196 
Clitoris, anatomy of, 17 
Coelio-hysterectomy, 339 

-hysterotomy, 332 
: Colostrum, 168 
j Colpitis, puerperal, svmptoms of, 

300 
: Complex presentations, 259 
Conception, 45 
| Cord, ligation of, 148 
management of, 147 
, Corpus luteum, 45 
Craniotomy, 345 

steps of, 345 
Cystitis, puerperal, symptoms of, 
300 
treatment of, 304 
Cystocele as a cause of dystocia, 237 



DECAPITATION, 349 
methods of, 349 
Deciduse, 55 

diseases of, 193 
Deficient lactation, signs of, 169 
measures for increasing the 
milk secretion in, 169 
Diabetes mellitus as a complica- 
tion of labor, 289 



IXDEX. 



353 



Diameters of fcetal head. See Fcetal 
head, measurements of 
of trunk, 108 
of pelvis, external, 95 
internal, 94 
measurement of, 131 
Diet of puerperal patient, 166 
Dilatation, stage of. management of, 
142' 
measures for relief of pain in, 

142 
special directions for manage- 
ment of, 142 
vaginal examinations in. 142 
Disorders of the newborn infant, 

184 
Double monsters, 261 
Draw-sheet, 158 



285 



ECLAMPSIA, 284 
clinical phenomena of, 
etiology of, 285 
prognosis of, 2S6 
treatment of, 287 
Ectopic gestation, 211 

clinical course of, 212 
diagnostic signs of, 214 
etiology of, 212 
treatment of, 216 
varieties of, 211 
Embryo, development of, 4S 

rate of, 59 
Embryotomy, 345 

indications for, 345 
Endometritis, puerperal, 298 
Episiotomy. 147 
Evisceration, 348 
Expelling forces regulation of, 146 

powers, 89 
Expulsion, stage of, management 
of, 143 
vaginal examination in, 144 
Extra-uterine pregnancy. See 
Ectopic gestation 



ACE presentation, 242 
causes of, 242 
diagnosis of, 243 
mechanism of, 242 



Face presentation, prognosis of. 244 

treatment of, 244 
Fallopian tubes, anatomy of, 34 
Feeble digestion in newborn child, 

management of, 181 
Fleshy mole, 204 
Fcetal circulation, 62 
death, 202 

treatment in, 204 
development, anomalies of, as 

causes of dystocia, 260 
bead, obstetric anatomy of, 104 
diameters of. See Fcetal head , 

measurements of. 
fontanelles of, 105 
measurements of, 106 
protuberances of, 106 
sutures of, 105 
heart-tones as a sign of preg- 
nancy, 76 
membranes, development of, 49 
movements, active, as a sign of 
pregnancy. 74 
passive as a sign of pregnancy, 
75 
Foetus, anomalies of development 
of, 201 
as a cause of dystocia, 260 
changes in, after death in utero. 

203 
death of See Fcetal death, 
diseases of, 202 
length of, in later months of 

pregnancy, 86 
pathology of, 201 
position of, 109 
posture of, 110 
presentation of, 108 
tumors of, as a cause of dvstocia, 

263 
rate of development of, 59 
Fontanelles of fcetal head, 105 
Forceps, 316 

application of, 319 
axis-traction. 325 
dangers of, 319 
in breech presentation, 324 
indications for, 318 



in oceipito-posterior position- 
324 



16* 



354 



INDEX. 



Forceps, mechanical action of, 317 
Fossa navicularis, 17 
Fourchette, 16 

Funis, prolapse of. See Prolapsus 
funis. 



riALACTORREKEA, 292 
U Genital organs, anatomy of, 
13 
external, anatomy of, 13 
internal, anatomy of, 25 
Graafian follicle, anatomy of, 39 
phenomena attending rupture 
of, 43 



HAND-CLEANING, technique 
of, 137 
Fiirbringer method of, 137 
permanganate method of, 138 
chlorinated soda method of, 
138 
Hegar's sign of pregnancy, 78 
Hemorrhage, accidental, 278 
ante-partum, 273 
from placenta praevia, 273 
post-partum, 280 
secondary post-partum, 283 
Hemorrhages, the, 273 
Hydramnios, 195 

Hydrocephalus as a cause of dys- 
tocia, 262 
Hygiene of pregnancy, 86 
Hymen, anatomy of, 19 



IMPREGNATION, 45 

L place, time, and mode of, 47 

Incubation of feeble infants, 174, 

311 _ 
Induction of abortion, 312 

of premature labor, 306 
Insanity, puerperal, 291 
Involution, 161 

of uterus, 161 
Ischio-cavernosus muscle, 103 



LABIA majora, anatomy of, 15 
minora, anatomy of, 15 



Labor, anomalies of, arising from 
accidents or disease, 264 
mechanism of, 224 
care of patient at close of, 157 
causes of onset of, 111 
duration of, 116 
length of, 121 
management of, 121 
in flat pelvis, 235 
mechanism of, 116 
mechanical factors of, 89 
normal, clinical and mechanical 

phenomena of, 111 
obstructed by anomalies of the 
hard parts, 228 
soft parts, 237 
pains, 113 
pathology of, 224 
perineal stage of, 120 
phenomena of beginning, 112 
physiology of, 89 
first stage of, 113 
second stage of, 116 
third stage of, 120 
placental stage of, 120 

duration of, 121 
precipitate, 224 
premature, 210 
prolonged, 224 
first stage of, 224 
second stage of, 227 
rules for predicting date of, 

85 
stage of dilatation of, 113 
duration of, 116, 120 
expulsion of, 116 
stages of, 111 

laceration of passages, 150 
lacerations, cervical, 150 
of pelvic floor, 150 
treatment of, 151 
Lactation and nursing, 168 
Levator ani muscle, 101 
Linear albicantes, 73 
Liquor amnii, 50 

anomalies of, 194 
Lochia, 163 
Lubricants for obstetrician's hand, 

139 _ 
Lying-in period, regulation of, 
168 



IXDJEX. 



355 



MAMMARY changes in preg- 
nancy, 69 
diagnostic value of, as signs of 
pregnancy, 72 
glands, increased size of, as a 
sign of pregnancy, 69 
Mastitis, 292 
causes of, 292 
diagnosis of, 293 
treatment of, 293 
Membranes, artificial rupture of, 
143 
foetal, 49 

management of, 149 
Menopause, 42 
Menstruation, 41 
Metritis, puerperal, 298 
Milk laboratories, 182 

secretion in pregnancy, 70 
Mons veneris, anatomy of, 13 
Montgomery's follicles, 70 
Moulding of the foetal head in 

labor, 120 
Multiple pregnancy, 83 

Y[AVEL dressing of newborn 

1> child, 175 

Nipples care of, during pregnancy, 
87 
treatment of sore, 294 

Normal labor, clinical and me- 
chanical phenomena of, 111 

Nursing the newborn child, 176 

Nymphse, anatomy of, 15 

OBSTETRIC position, 143 
surgery, 306 

of the abdomen. 332 
Occipito posterior position, 240 
Occiput, definition of, 106 
Oligohydramnios, 194 
Ophthalmia of newborn child, 189 
Os externum uteri occlusion of, as 

a cause of dystocia, 238 
Ovaries, anatomy of, 37 
Oviducts. See Fallopian tubes. 
Ovulation, 41 
Ovum, anatomy of, 43 

development of impregnated, 47 

physiology of, 41 



PARAMETRITIS, puerperal, 
symptoms of, 298 
treatment of, 304 
Parovarium, 40 
Parturient axis, 103 
Passages, anomalies of, as affecting 
labor, 228 
laceration of, 150 
obstetric, anatomy of, 90 
Passenger, anomalies of, as causes 
of dystocia, 240 
as a factor of labor, 104 
Pasteurizing, methods of, 179 
Pathology of pregnancy, 193 
Patient, obstetric, aseptic prepara- 
tion of, 139 
ante-partum, examination of, 

122 
examination of, during labor, 
140 
Pelves, deformed, 228 
Pelvic deformity, diagnosis of, 234 
-floor, anatomy of, 99 
fascial sheets of, 100 
lacerations of, 150 

treatment of, 151 
muscles of, 101 

prevention of lacerations of, 
146 
signs of pregnancy, 77 
soft parts, obstetric anatomv of, 98 
Pelvimetry, 131, 234 
external, 131 
internal, 132 
Pelvis, brim of, 91 

differences between male and 

female, 97 
flattened and generallv con- 
tracted, 230 
funnel-shaped, 230 
justo-minor, 230 
kyphotic, 230 
measurements of, 96 
Nsegele oblique, 231 
narrowing of, from bonv tumors, 

233 
obstetric, anatomy of bony, 90 
ordinary oblique-ovate, 232 
osteomalacic, 233 
outlet of bony, 91 
planes of, 93 



356 



INDEX. 



Pelvis, Eoberts', 232 
simple flat, 229 
spondylolisthetic, 232 
Perineal body, 103 
Peritonitis, puerperal, symptoms 
of diffuse, 299 
treatment of, 303 
Phlegmasia alba dolens, symptoms 
of, 299 
treatment of, 304 
Physiology of labor, 89 

of the puerperal state, 160 
Placenta and membranes, examina- 
tion of, at close of labor, 150 
anatomy of, 56 
anomalies of, 197 
degeneration of, 199 

white infarcts of, 199 
delivery of, 148 
development of, 58 
manual extraction of, 149 
previa, 198-273 
causes of, 273 
physical signs of, 274 
symptoms of, 274 
treatment of, 275 
removal of abnormally adherent, 

315 
syphilis of, 198 
Placental stage managementof, 148 
Polyhydramnios, 195 
Porro operation, 339 
indications for, 339 
steps of, 339 
Position of foetus, 109 
Post-partum chill, 160 
hemorrhage, 280 
causes of, 281 
diagnosis of. 281 
treatment of, 281 
secondary 283 
visits, 163 
Posture of foetus, 110 
Powers, expelling, 89 
anomalies of, 224 
Pregnancy, abdominal signs of, 72 
care of nipples in, 87 
changes in cervix uteri in, 66 

uterus in, 64 
clothing in, 87 
duration of, 84 



Pregnancy, ectopic. See Ectopic 
gestation, 
effects of, on maternal organism, 

64 
general changes in, 67 
hygiene of, 86 

hygienic requirements in, 87 
mammary changes as signs of, 69 
multiple, 83 

origin of, 83 
nausea as a sign of, 69 
pathology of, 193 
pelvic signs of, 77 
physical signs of, 69 
physiology of, 41 
ptyalism as a sign of, 69 
pulsation of uterine artery as a 

sign of, 80 
signs of, 68 
suppression of menses as a sign 

of, 68 
temperature of cervix uteri as a 
sign of, 80 
Premature labor, indications for, 
306 
induction of, 306 
methods of, 307 
Presentation, breech, 247 
brow, 246 
face, 242 

methods for converting, into 
vertex, 245 
of foetus, 108 
shoulder, 256 
transverse, 256 
vertex See Normal labor. 
Presentations, complex, treatment 
• of, 259 
i Prolapsus funis, 264 
diagnosis of, 265 
prognosis of, 265 
treatment of, 265 
Protuberances of foetal head, 106 
Ptyalism in pregnancy, 222 
Pruritus vulvae in pregnancy, 223 
Puberty, 42 

Pubic segment of pelvic floor, re- 
traction of, during labor, 116 
Pudendum, anatomy of, 13 

lymphatics, and nerves 
of, 20 



INDEX, 



357 



Puerperal infection, 295 

diagnosis of, 297 

etiology of, "296 

special manifestations of, 297 

symptoms of special lesions in 
298 

treatment of, 301 
insanity, 291 

causes of, 291 

prognosis of, 291 

treatment of, 291 
state, condition of uterus in, 161 

course and phenomena of, 160 

management of, 163 

pathology of, 291 

physiology in, 160 

pulse-rate in, 160 

temperature in, 160 
Pysemia, puerperal, 300 

treatment of, 304 



RECTOCELE as a cause of dys- 
tocia, 237 
Retention of urine after labor, 165 
Retraction ring, 115 

of uterus at close of labor, 121 



Sutures of foetal head, 105 
Symphysiotomy, 340 

after-treatment of, 345 

indications for, 340 

method of operating in, 341 

results of, 340 

space gained in, 340 
Symphysis pubis, separation of, 

283 



TRANSVERSE presentation, 
1 256 

causes of, 256 
diagnosis of, 257 
treatment of, 258 
Transversus perinei, 102 
Triangular ligament, 101 
Trunk, delivery of, 147 
Tumors, maternal, as causes of 
dystocia, 238 
foetal, as causes of dystocia, 263 
Twins, 260 

arrangement of membranes and 

placentas in, 84 
diagnosis of, 260 
interlocking, 261 



OEMINAL fluid, 46 

O Septicaemia puerperal See 
Puerperal infection, 
pure, symptoms of, 300 

Serous effusions into foetal cavities 
as a cause of dystocia, 263 

Shoulder presentation See Trans- 
verse presentation. 

Signs of pregnancy, 68 

summary of diagnostic, 81 

Sinciput, definition of, 106 

Somatopleure, 49 

Souffle, funic, 75 
uterine, 75 

Spermatozoa, 46 

Sphincter ani externus, 103 

Splanchnopleure 49 

Stages of labor, 111 

Subinvolution of uterus, 166 

Sudden death in childbed, 305 

Superfecundation, 84 

Superfoetation, 84 



UMBILICAL cord, anatomy of, 
59 
anomalies of, 199 
hemorrhage in newborn child, 

191 
infection in newborn child, 190 
Uretero-pyelitis in puerperal pe- 
riod, symptoms of, 301 
treatment of, 305 
Urethra, anatomy of, 23 
Urine, observation of the, during 

pregnancy, 88 
Uterus, anatomy of, 25 
arteries of, 32 
cavity of, 28 
changes in, during pregnancy, 

64 
developmental anomalies of, 

239 
gravid, dimensions of, 65 
shape of, 65 
size of, 64 



358 



INDEX. 



Uterus, intermittent contractions 

of, in pregnancy, 74 
inversion of, 267 

diagnosis of, 268 

etiology of, 267 

treatment of, 268 
involution of, after labor, 161 

subinvolution of, 166 
ligaments of, 31 
lymphatics of, 34 
nulliparous and parous, 30 
position of, 31 
regional divisions of, 28 
rupture of, 269 

diagnosis of, 271 

etiology of, 270 

prognosis of, 271 

treatment of, 271 
Uterine tumor of pregnancy, 
changes in, 78 



YTAGINA, anatomy of 20 
t purplish color of, in preg 
nancy, 77 



Vaginal examination in second 

stage of labor, 144 
Varices of lower extremities in 

pregnancy, 223 
Veins, mammary, enlargement of, 

during pregnancy, 70 
Version, 326 

bipolar, 328 

external, 328 

indications for, 327 

internal, 331 
Vertex of foetal head, definition 
of, 106^ 

presentation. See Normal labor. 
Vesicular mole, 196 
Vestibule, 17 
Villi, chorial, 53 

Vomiting of pregnancy. See Preg- 
nancy, nausea of, 
pernicious, 219 
etiology of, 219 
treatment of, 220 
Vulvar dressing at close of labor, 

158 
Vulvo-vaginal glands, 19 



CATALOGUE OF PUBLICATIONS OF 

LEA BROTHERS & COMPANY, 

706, 708 & 710 Sansoin St., Philadelphia. 
Ill Fifth Ave. (Cor. 18th St.), New York. 

The books in the annexed list will be sent by mail, post-paid, to any Post-Office in the 
United States, on receipt of the printed prices. 



INDEX. 

ANATOMY. Gray, p. 11 ; Allen, 2 ; Treves (Surgical), 30 ; Ellis, 9. 

DICTIONARIES. Dunglison, p. 8 ; Duane, 8 ; National, 4. 

PHYSICS. Draper, p. 8 ; Eobertson. 24. 

PHYSIOLOGY. Foster, p. 10 ; Dalton, 7 ; Chapman, 5 ; Powers, 23 
Schofield, 25. 

CHEMISTRY. Simon, p. 26 ; Attfield, 3 ; Fownes, 10 ; Charles, 6 

PHARMACY. Caspari, p. 5. [Luff, 19 ; Kemsen, 24. 

MATERIA MEDICA. Culbretb, p. 6 ; Maisch, 19 ; Farquharson, 9 

DISPENSATORY. National, p. 21. [Bruce, 4. 

THERAPEUTICS. Hare, pp. 13 ; Fothergill, 10 ; Whitla, 31 ; Year- 
Book. 31 ; Hayem & Hare, 14. 

PRACTICE. Flint, p. 9 ; Loomis & Thompson, 19 ; Lyman, 19. 

DIAGNOSIS. Musser, p. 21 ; Hare, 12; Simon, 25 ; Herrick, 15. 

CLIMATOLOGY. Solly, p. 26 ; Hayem & Hare, 14. 

NERVOUS DISEASES. Dercuni, p. 7 ; Gray, 11 ; Mitchell, 20 ; 
Hamilton, 12. 

MENTAL DISEASES. Clouston, p. 6 ; Savage, 24 ; Folsom, 10. 

BACTERIOLOGY. Abbott, p. 2 ; Vaughan & Novy, 30 ; Senn's 
(Surgical), 25. 

HISTOLOGY. Klein, p. 18 ; Schafer's Essen., 25 ; Schafer's Pract., 25. 

PATHOLOGY. Green, p. 12; Gibbes, 10; Coats, 6; Pepper (Surgical), 23. 

SURGERY. Park, p. 22; Dennis, 7; Roberts, 24; Ashhurst, 3; Treves, 29; 
Bryant, 5 ; Druitt. 8. 

SURGERY— OPERATIVE. Stimson, p. 27 ; Smith, 26 ; Treves, 29. 

SURGERY— ORTHOPEDIC. Young, p. 31 ; Gibney, 11. 

SURGERY— MINOR. Wharton, p. 30. 

FRACTURES and DISLOCATIONS. Hamilton, p. 12; Stimson, 27. 

OPHTHALMOLOGY. Norris & Oliver, p. 21; Nettleship, 21; Juler,17; 

OTOLOGY. Politzer, p. 23 ; Burnett, 5 ; Field, 9. [Berry, 4. 

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MEDICAL JURISPRUDENCE. Taylor, p. 28. 

QUIZ SERIES and MANUALS. Pp. 25 and 27. 
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DE LA BECHE'S GEOLOGICAL OBSERVER. In one large octavo 
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DUANE (ALEXANDER). THE STUDENT'S DICTIONARY OF 
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DUNGLISON (ROBLEY). A DICTIONARY OF MEDICAL SCI- 
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EMMET (THOMAS ADDIS). THE PRINCIPLES AND PRAC- 
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ESSIG (CHARLES J.). PROSTHETIC DENTISTRY. Just ready. 
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FIELD (GEORGE P.). A MANUAL OF DISEASES OF THE 
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Lancet. 

The best of American text-books 
on Practice. — Amer .Medico-Su rgical 
Bulletin. 



— A MANUAL OF AUSCULTATION AND PERCUSSION; of 
the Physical Diagnosis of Diseases of the Lungs and Heart, and of 
Thoracic Aneurism. Fifth edition, revised by James C. Wilson, M. D. 
In one handsome 12mo. volume of 274 pages, with 12 engravings. 

— A PRACTICAL TREATISE ON THE DIAGNOSIS AND 
TREATMENT OF DISEASES OF THE HEART. Second edition, 
enlarged. In one octavo volume of 550 pages. Cloth, $4. 

— A PRACTICAL TREATISE ON THE PHYSICAL EXPLO- 
RATION OF THE CHEST, AND THE DIAGNOSIS OF DIS- 
EASES AFFECTING THE RESPIRATORY ORGANS. Second 
and revised edition. In one octavo volume of 591 pages. Cloth, $4.50. 

— MEDICAL ESSAYS. In one 12mo. vol. of 210 pages. Cloth, $1.38. 

— ON PHTHISIS : ITS MORBID ANATOMY, ETIOLOGY, ETC. 
A Series of Clinical Lectures. In one 8vo. volume of 442 pages. 
Cloth, $3.50. 



10 Lea Brothers & Co., Philadelphia and New York. 



FOLSOM (C. F.). AN ABSTRACT OF STATUTES OF U. S. 
ON CUSTODY OF THE INSANE. In one 8vo. vol. of 108 pages. 
Cloth, $1.50. With Clouston on Mental Diseases (new edition, see 
page 6) $5.50 for the two works. 

FOSTER (MICHAEL). A TEXT-BOOK OF PHYSIOLOGY. New 

(6th) and revised American from the sixth English edition. In one 
large octavo volume of 923 pages, with 257 illustrations. Cloth, $4.50 ; 
leather, $5.50. 



Unquestionably the best book that 
can be placed in the student's hands, 
and as a work of reference for the 
busy physician it can scarcely be 
excelled. — The Phila. Polyclinic. 

The leading text-book used by 
English-speaking students. This 
single volume contains all that will 



be necessary in a college course, and 
it may be safely added all that the 
physician will need as well. — Do- 
minion Med. Monthly. 

For physician, student, or teacher 
this is and long will remain the 
standard, up-to-date work on physi- 
ology. — Virginia Medical Monthly. 



FOTHERGILL (J. MILNER). THE PRACTITIONER'S hand- 
book OF TREATMENT. Third edition. In one handsome octavo 
volume of 664 pages. Cloth, $3.75 ; leather, $4.75. 



To have a description of the 
normal physiological processes of an 
organ and of the methods of treat- 
ment of its morbid conditions 
brought together in a single chapter, 
and the relations between the two 



clearly stated, cannot fail to prove 
a great convenience to many thought- 
ful but busy physicians. The prac- 
tical value of the volume is greatly 
increased by the introduction of many 
prescriptions — New York Med. Jour. 



POWNES (GEORGE). A MANUAL OF ELEMENTARY CHEM- 
ISTRY (INORGANIC AND ORGANIC). Twelfth edition. Em- 
bodying Watts' Physical and Inorganic Chemistry. In one royal 
12mo. volume of 1061 pages, with 168 engravings, and 1 colored 
plate. Cloth, $2.75 ; leather, $3.25. 

FRANKLAND (E.) AND JAPP (F.R.). INORGANIC CHEMISTRY. 
In one handsome octavo volume of 677 pages, with 51 engravings and 
2 plates. Cloth, $3.75 ; leather, $4.75. 

FULLER (EUGENE). DISORDERS OF THE SEXUAL OR- 
GANS IN THE MALE. In one very handsome octavo volume of 
238 pages, with 25 engravings and 8 full-page plates. Cloth, $2. 
Just ready. 
It is an interesting work, and one tive and brings views of sound 
which, in view of the large and pathology and rational treatment to 
profitable amount of work done in many cases of sexual disturbance 
this field of late years, is timely and whose treatment has been too often 
well needed. — Medical Fortnightly, fruitless for good. — Annals of 
The book is valuable and instruc- Surgery. 

FULLER (HENRY). ON DISEASES OF THE LUNGS AND AIR 
PASSAGES. Their Pathology, Physical Diagnosis, Symptoms and 
Treatment. From second English edition. In one 8vo. volume of 475 
pages. Cloth, $3.50. 

GANT (FREDERICK JAMES). THE STUDENT'S SURGERY. A 
Multum in Parvo. In one square octavo volume of 845 pages, with 
159 engravings. Cloth, $3.75. 

GIBBES (HENEAGE). PRACTICAL PATHOLOGY AND MOR- 
BID HISTOLOGY. In one very handsome octavo volume of 314 
pages, with 60 illustrations, mostly photographic. Cloth, $2.75. 



Lea Brothers & Co., Philadelphia and New York. 11 

GIBNEY (V. P.). OETHOPEDIC SURGERY. For the use of Practi- 
tioners and Students. In one 8vo. vol. profusely illus. Preparing. 

GOULD (A. PEARCE). SURGICAL DIAGNOSIS. In one 12mo. 

vol. of 589 pages. Cloth, $2. See Student's Series of Manuals, p. 27. 



GRAY (HENRY). ANATOMY, DESCRIPTIVE AND SURGICAL. 

New and thoroughly revised American edition, much enlarged in text, 
and in engravings in black and colors. In one imperial octavo volume 
of 1239 pages, with 772 large and elaborate engravings on wood. Price 
of edition with illustrations in colors : cloth, $7 ; leather, $8. Price 
of edition with illustrations in black : cloth, $6 ; leather, $7. Just ready. 



This is the best single volume 
upon Anatomy in the English 
language. A thorough knowledge 
of the subject is acquired without 
consulting other books. As a work 
of reference for the surgeon or prac- 
titioner it has no superior. — Uni- 
versity Medical Magazine. 

This edition has been revised to 
adapt it thoroughly to the require- 
ments of teachers and students of 
the present day. The illustrations 
in Gray's Anatomy have always 
been one of its especial features ; 
each bone, ligament, muscle, nerve, 
artery and tissue has been appro- 
priately labelled, and in late editions 
have appeared in colors where 
essential. Gray's Anatomy affords 
the student more satisfaction than 
any other treatise with which we 
are familiar. — Buffalo 3Ied. Journal. 

The most largely used anatomical 
text-book published in the English 
language. — Annals of Surgery. 



Gray's Anatomy, in spite of the 
efforts which have been made from 
time to time to displace it, still holds 
first place in the esteem of both 
teachers and students. — The Brook- 
lyn Medical Journal. 

Particular stress is laid upon the 
practical side of anatomical teach- 
ing, and especially the Surgical 
Anatomy. — Chicago Med. Recorder. 

The foremost of all medical text- 
books. — Medical Fortnightly. 

Gray's Anatomy should be the 
first work which a medical student 
should purchase, nor should he be 
without a copy throughout his pro- 
fessional career. — Pittsburg Medical 
Review. 

This new edition of Gray is a 
matchless treatise upon Human Ana- 
tomy. Medical students and prac- 
titioners desiring a complete library 
on anatomy will make no mistake 
in purchasing Gray. — Tri-State Med. 
Journal. 



GRAY (LANDON CARTER). A TREATISE ON NERVOUS AND 
MENTAL DISEASES. For Students and Practitioners of Medicine. 
New (2d) edition. In one handsome octavo volume of 728 pages, with 
172 engravings and 3 colored plates. Cloth, $4.75 ; leather, $5.75. 



We have here what has so often 
been desired — an up-to-date text- 
book upon nervous and mental dis- 
eases combined. A well-written, 
terse, explicit, and authoritative vol- 
ume treating of both subjects is a 
step in the direction of popular de- 
mand. — The Chicago Clinical Re- 
view. 

" The word treatment," says the 
author, "has been construed in the 
broadest sense to include not only 
medicinal and non-medicinal agents, 



but also those hygienic and dietetic 
measures which are often the physi- 
cian's best reliance." — The Journal 
of the American Medical Association. 
The descriptions of the various 
diseases are accurate and the symp- 
toms and differential diagnosis are 
set before the student in such a way 
as to be readily comprehended. The 
author's long experience renders his 
views on therapeutics of great value. 
— The Journal of Nervous and Men- 
tal Disease. 



detail of text sufficient explanation. 
The work is an essential to the prac- 
titioner — whether as surgeon orphys- 
ician. It is the best of up-to date 
text-books. — Virgin ia Jled. Mon th ly. 



12 Lea Brothers & Co., Philadelphia and New York. 

GREEN (T. HENRY). AN INTRODUCTION TO PATHOLOGY 
AND MORBID ANATOMY. New (7th) American from the eighth 
London edition. In one handsome octavo volume of 595 pages, with 
224 engravings and a colored plate. Cloth, $2.75. 
A work that is the text-book of of the day — as much so almost as 
probably four-fifths of all the stu- j Gray's Anatomy. It is fully up-to- 
dents of pathology in the United | date in the record of fact, and so pro- 
States and Great Britain stands in j fusely illustrated as to give to each 
no need of commendation. The work 
precisely meets the needs and wishes 
of the general practitioner. — The 
American Practitioner and News. 
Green's Pathology is the text-book 

GREENE (WILLIAM H.). A MANUAL OF MEDICAL CHEM- 
ISTRY. For the Use of Students. Based upon Bowman's Medical 
Chemistry. In one 12mo. vol. of 310 pages, with 74 illus. Cloth, $1.75. 

GROSS (SAMUEL D.). A PRACTICAL TREATISE ON THE DIS- 
EASES, INJURIES AND MALFORMATIONS OF THE URINARY 
BLADDER, THE PROSTATE GLAND AND THE URETHRA. 
Third edition, thoroughly revised and edited by Samuel W. Gross, 
M. D. In one octavo vol. of 574 pages, with 170 illus. Cloth, $4.50. 

HABERSHON (S. O.). ON THE DISEASES OF THE ABDOMEN, 
comprising those of the Stomach, (Esophagus, Caecum, Intestines 
and Peritoneum. Second American from the third English edition. 
In one octavo volume of 554 pages, with 11 engravings. Cloth, $3.50. 

HAMILTON (ALLAN MCLANE). NERVOUS DISEASES, THEIR 
DESCRIPTION AND TREATMENT. Second and revised edition. 
In one octavo volume of 598 pages, with 72 engravings. Cloth, $4. 

HAMILTON (FRANK H.). A PRACTICAL TREATISE ON FRAC- 
TURES AND DISLOCATIONS. Eighth edition, revised and edited 
by Stephen Smith, A. M., M. D. In one handsome octavo volume of 
832 pages, with 507 engravings. Cloth, $5.50 ; leather, $6.50. 
Its numerous editions are convin- I cent revision make it a work thor- 
cing proof of its value and popular- oughly in accordance with modern 
ity. It is preeminently the authority practice theoretically, mechanically, 
on fractures and dislocations. The aseptically. — Boston Medical and 
additions it has received by its re- j Surgical Journal. 

HARD A WAY (W. A.). MANUAL OF SKIN DISEASES. In one 

12mo. volume of 440 pages. Cloth, $3. 

HARE (HOBART AMORY). PRACTICAL DIAGNOSIS. THE 

USE OF SYMPTOMS IN THE DIAGNOSIS OF DISEASE. In 

one octavo volume of 566 pages, with 191 engravings and 13 full-page 

colored plates. Cloth, $4.75. Just ready. 

This book is one of the best of its observer, will pay more attention to 

kind we have ever had the pleasure the simple yet indicative signs of 

to peruse. It is a great triumph of disease, and he will become a hetter 

the author to encompass such an diagnostician. Tlietwoinoispensable 

enormous number of practical points indexes— Index of Diseases, and In- 

in a work of convenient size. Its dex of Symptoms, Organs and Terms 

great practical utility is sugg-ested make the work especially valuable as 

by the title. The logical sequence of a clinical manual. This is a compan- 

the book is to lead to a diagnosis ion to Practical Therapeutics, by 

from a study and grouping of individ- the same author, and it is difficult to 

ual symptoms. Anyone who reads conceive of any two works of greater 

this book will become a more acute -practical utility. — Medical Review. 



Lea Brothers & Co., Philadelphia and New York. 13 

HARE (HOBART AMORY). A TEXT-BOOK OF PRACTICAL 

THERAPEUTICS, with Special Reference to the Application of Reme- 
dial Measures to Disease and their Employment upon a Rational 
Basis. With articles on various subjects by well-known specialists. 
New (5th) and revised edition. In one octavo volume of 740 pages. 
Diagonal cloth, $3.75 ; leather, $4.75. 



Five editions in as many years 
constitute a remarkable record for 
any book, and, futhermore, an evi- 
dence that medical teachers and 
practitioners appreciate a work 
closely adapted to their require- 
ments. Professor Hare is well 
known as a progressive and able 



nection by means of references, so 
that a knowledge of any subject 
treated is easily gained. Ease of 
reference is, moreover, provided for 
in the highest degree by the alpha- 
betical arrangement of the book and 
by the two full indexes. Practi- 
tioners will find the Therapeutical 



therapeutist and teacher, and his Index, in which all the remedial 
ability in both directions is attested | measures are listed with brief anno- 
in the highly original plan of this J tations under the headings of the sev- 
work, as well as in its execution. His [ eral diseases, most suggestive and ser- 
purpose has clearly been to bring a viceable. Like preceding issues, the 
knowledge of the remedial agents into present edition has been revised to 
close relation with a knowledge of; the latest date. — Columbus Medical 
disease. The book consists essentially j Journal. 

of two parts, the first being a treatise It is a book precisely adapted to 
on therapeutics, both medicinal and the needs of the busy practitioner, 
non-medicinal ; the second being a who can rely upon finding exactly 
treatise on disease, its symptoms, j what he needs. — The National Med- 
varieties, treatment, etc. The two i ical Review. 
parts are brought into direct con- 1 

HARE (HOBART AMORY, EDITOR). A SYSTEM OF PRAC- 
TICAL THERAPEUTICS. In a series of contributions by eminent 
practitioners. In four large octavo volumes comprising about 4500 
pages,with about 550 engravings. Vol. IV., just ready. For sale by sub- 
scription only. Full prospectus free on application to the Publishers. 
Regular price, Vol. IV., cloth, $6 ; leather, $7 ; half Russia, $8. 
Price Vol. IV. to former or new subscribers to complete work, cloth, 
$5 ; leather, $6 ; half Russia, $7. Complete work, cloth, 820 ; leather, 
$24 ; half Russia, $28. 

The great value of Hare's System of Practical Therapeutics has led to a 
widespread demand for a new volume to represent advances in treatment 
made since the publication of the first three. More than fulfilling this 
request the Editor has secured contributions from practically a new corps 
of equally eminent authors, so that entirely fresh and original matter is 
ensured. The plan of the work, which proved so successful, has been fol- 
lowed in this new volume, which will be found to present the latest devel- 
opments and applications of this most practical branch of the medical art. 
Prescriptions indicative of the manner in which particular drugs are admin- 
istered are frequently inserted, with the aim of making the work as helpful 
as possible ; and especial care is devoted to such precision of detail as 
will render it a safe guide in the use of the newer and less familiar agents. 
This volume will therefore be indispensable to the many thousands of 
subscribers to the original work, and it will be of no less value by itself, 
since it reflects the whole position of each subject. The entire System is 
an unrivalled eucyclopcedia on the practical parts of medicine, and merits 
the great success it has won for that reason. 



14 Lea Brothers & Co., Philadelphia and New York. 

HARTSHORNE (HENRY). ESSENTIALS OF THE PRINCIPLES 
AND PRACTICE OF MEDICINE. Fifth edition. In one 12mo. 
volume, 669 pages, with 144 engravings. Cloth, $2.75 ; half bound, $3. 

A HANDBOOK OF ANATOMY AND PHYSIOLOGY. In one 

12mo. volume of 310 pages, with 220 engravings. Cloth, $1.75. 

A CONSPECTUS OF THE MEDICAL SCIENCES. Comprising 

Manuals of Anatomy, Physiology, Chemistry, Materia Medica, Prac- 
tice of Medicine, Surgery and Obstetrics. Second edition. In one royal 
12mo. vol. of 1028 pages, with 477 illus. Cloth, $4.25 ; leather, $5. 

HAYDEN ( JAMES R.). A MANUAL OF VENEREAL DISEASES. 

In one 12mo. volume of 263 pages, with 47 engravings. Cloth, $1.50. 
Just ready. 

It is practical, concise, definite i ticularly thorough, and may be 
and of sufficient fulness to be satis- j relied upon as a guide in the man- 
factory. — Chicago Clinical Review. ■ agement of this class of diseases. — 

This work gives all of the prac- Northivestem Lancet. 
tically essential information about | It is well written, up to date, and 
the three venereal diseases, gon- will be found very useful. — Inter- 
orrhcea, the chancroid and syphilis, i national Medical Magazine. 
In diagnosis and treatment it is par- 1 

HAYEM (GEORGES) AND HARE (H. A.) PHYSICAL AND 
NATURAL THERAPEUTICS. The Remedial Use of Heat, Elec- 
tricity, Modifications of Atmospheric Pressure, Climates and Mineral 
Waters. Edited by Prof. H. A. Hare, M. D. In one octavo volume 
of 414 pages,with 113 engravings. Cloth, $3. 

This well-timed up-to-date volume j recognition. Within this large 
is particularly adapted to the re- | range of applicability, physical 
quirements of the general practi- 
tioner. The section on mineral 
waters is most scientific and prac- 
tical. Some 200 pages are given up 
to electricity and evidently embody 
the latest scientific information on 
the subject. Altogether this work 
is the clearest and most practical aid 
to the study of nature's therapeutics 
that has yet come under our obser- 
vation. — The Medical Fortnightly. 

For many diseases the most potent 
remedies lie outside of the materia 
medica, a fact yearly receiving wider 



agencies when compared with drugs 
are more direct and simple in their 
results. Medical literature has long 
been rich in treatises upon medical 
agents, but an authoritative work 
upon the other great branch of 
therapeutics has until now been a 
desideratum. The section on climate, 
rewritten by Prof. Hare, will, for 
the first time, place the abundant 
resources of our country at the in- 
telligent command of American 
practitioners. — The Kansas City 
Medical Index. 



HERMAN (G. ERNEST). FIRST LINES IN MIDWIFERY. In 

one 12mo. vol. of 198 pages, with 80 engravings. Cloth, $1.25. See 
Student's Series of Manuals, page 27. 

HERMANN (L..). EXPERIMENTAL PHARMACOLOGY. A Hand- 
book of the Methods for Determining the Physiological Actions of 
Drugs. Translated by Robert Meade Smith, M. D. In one 12rao, 
volume of 199 pages, with 32 engravings, Cloth, $1,50, 



Lea Brothers & Co., Philadelphia and New York. 15 



HERRICK (JAMES B.). A HANDBOOK OF DIAGNOSIS. In 

one handsome 12mo. volume of 429 pages, with 80 engravings and 2 
colored plates. Cloth, $2.50. 



Excellently arranged, practical, 
concise, up-to-date, and eminently 
well fitted for the use of the prac- 
titioner as well as of the student. — 
Chicago Med. Recorder. 

This volume accomplishes its ob- 
jects more thoroughly and com- 
pletely than any similar work yet 
published. Each section devoted to 
diseases of special systems is pre- 
ceded with an exposition of the 
methods of physical, chemical and 



microscopical examination to be em- 
ployed in each class. The technique 
of blood examination, including color 
analysis, is very clearly stated. 
Uranalysis receives adequate space 
and care. — New York Med. Journal. 
We commend the book not only to 
the undergraduate, but also to the 
physician who desires a ready means 
of refreshing his knowledge of diag- 
nosis in the exigencies of professional 
life. — Memphis Medical Monthly. 



HILL (BERKELEY). SYPHILIS AND LOCAL CONTAGIOUS 

DISORDERS. In one 8vo. volume of 479 pages. Cloth, $3.25. 

HLLLIER (THOMAS). A HANDBOOK OF SKIN DISEASES. 
Second edition. In one royal 12mo. volume of 353 pages, with two 
plates. Cloth, $2.25. 

HIRST (BARTON C.) AND PD3RSOL (GEORGE A.). HUMAN 

MONSTROSITIES. Magnificent folio, containing 220 pages of text 
and illustrated with 123 engravings and 39 large photographic plates 
from nature. In four parts, price each, $5. Limited edition. For sale 
by subscription only. 

HOBLYN (RICHARD D.). A DICTIONARY OF THE TERMS 
USED IN MEDICINE AND THE COLLATERAL SCIENCES. 
In one 12mo. volume of 520 double-columned pages. Cloth, $1.50 ; 
leather, $2. 

HODGE (HUGH L.). ON DISEASES PECULIAR TO WOMEN, 
INCLUDING DISPLACEMENTS OF THE UTERUS. Second and 
revised edition. In one 8vo. vol. of 519 pp., with illus. Cloth, $4.50. 

HOFFMANN (FREDERICK) AND POWER (FREDERICK B.). 

A MANUAL OF CHEMICAL ANALYSIS, as Applied to the 
Examination of Medicinal Chemicals and their Preparations. Third 
edition, entirely rewritten and much enlarged. In one handsome octavo 
volume of 621 pages, with 179 engravings. Cloth, $4.25. 

HOLDEN (LUTHER). LANDMARKS, MEDICAL AND SURGI- 
CAL. From the third English edition. With additions by W. W. 
Keen, M. D. In one royal 12mo. volume of 148 pages. Cloth, $1. 



HOLMES (TIMOTHY). A TREATISE ON SURGERY. Its Prin- 
ciples and Practice. A new American from the fifth English edition. 
Edited by T. Pickering Pick, F.R.C.S. In one handsome octavo vol- 
ume of 100S pages, with 428 engravings. Cloth, $6 ; leather, $7. 



— A SYSTEM OF SURGERY. With notes and additions by various 
American authors. Edited by John H. Packard, M. D. In three 
very handsome 8vo. volumes containing 3137 double-columned pages, 
with 979 engravings and 13 lithographic plates. Per volume, cloth, $6 ; 
leather $7 ; half Russia, $7.50, For sale by subscription only, 



16 Lea Beothees & Co.. Philadelphia and New Yoek. 



HORNER (WILLIAM E.). SPECIAL ANATOMY AND HIS- 
TOLOGY. Eighth edition, revised and modified. In two large 8vo. 
volumes of 1007 pages, containing 320 engravings. Cloth, $6. 



HUDSON (A.). LECTUKES ON THE STUDY OF FEVER. 

octavo volume of 308 pages. Cloth, $2.50. 



In one 



HUTCHINSON (JONATHAN). SYPHILIS. In one pocket-size 12mo. 
volume of 542 pages, with 8 chromo-lithographic plates. Cloth, $2.25. 
See Series of Clinical Manuals, p. 25. 



HYDE (JAMES NEVINS). A PRACTICAL TREATISE ON DIS- 
EASES OF THE SKIN. New (4th) edition, thoroughly revised. 
In one octavo volume of 815 pages, with 110 engravings and 12 full- 
page plates, 4 of which are colored. Cloth, $5.25 ; leather, $6.25. 
Just ready. 



Almost every page of this edition 
has been carefully revised, and 
every real advance has been recog- 
nized. The work answers the needs 
of the general practitioner, the 
specialist, and the student, and is 
a happy example of the fact that 
such an apparently wide range of 
adaptation can be given within the 
compass of a volume of convenient 
size and price. — The Ohio Med. Jour. 

A treatise of exceptional merit 
characterized by conscientious care 
and scientific accuracy. — Buffalo 
Med. Journal. 

Those who wish the latest views 
may confidently consult its pages. — 
University Med. Magazine. 

A complete exposition of our 
knowledge of cutaneous medicine as 
it exists to-day. The teaching in- 



culcated throughout is sound as well 
as practical. — The American Jour- 
nal of the Medical Sciences. 

It is the best one- volume work 
that we know. The student who 
gets this book will find it a useful 
investment, as it will well serve him 
when he goes into practice. — Vir- 
ginia Medical Semi-Monthly. 

A full and thoroughly modern 
text-book on dermatology. — The 
Pittsburg Medical Review. 

All new facts based on path- 
ological and bacteriological re- 
searches have been considered in 
detail, and in every way this book 
represents the Dermatology of to- 
day. It is the most practical hand- 
book on dermatology with which we 
are acquainted. — The Chicago Med- 
ical Recorder. 



JACKSON (GEORGE THOMAS). THE READY-REFERENCE 
HANDBOOK OF DISEASES OF THE SKIN. New (2d) edition. 
In one 12mo. volume of 589 pages, with 69 illustrations and a colored 
plate. Cloth, $2.75. Just ready. 



The specialist will find it a prompt 
and ready source of knowledge on 
all points of terminology, symptoms, 
varieties, etiology, pathology, diag- 
nosis, treatment and prognosis of 
dermal affections. Tables of differ- 
ential diagnosis and standard pre- 
scriptions will be found scattered 
through the text, and the work ends 
with an appendix of well-tried 
formulae. The series of illustra- 
tions is rich and instructive. — Mem- 
phis Medical Monthly. 

The text is clear and sufficiently 
full. The subject of treatment in- 



cludes all the newer methods and 
remedies of proved value. It is a 
thoroughly satisfactory and clear 
expression of cutaneous diseases. — 
American Journal of the Medical 
Sciences. 

The work is fair and accurate, full 
and complete, and it embodies the 
recent additions to our information. 
Above all, it is eminently practical. 
The reviewer has found it a good 
book for students, and believes it is 
equally good for the practitioner. — 
Chicago Clinical Review. 



Lea Brothees & Co., Philadelphia axd New Yoek. 17 



JA3ILESON (W. ALLAV . DISEASES OF THE SKIN. Third 
edition. In one octavo volume of 656 pages, with 1 engraving and 9 
double-page chromo-lithographic plates. Cloth, $6. 

JEWETT (CHARLES). ESSENTIALS OF OBSTETEICS. In one 
12mo. volume of 356 pasres, with 78 en?ravinsrs and 3 colored plates. 

Cloth, $2.25. Just ready. 

JOXES (C. HANDFLELD\ CLINICAL OBSERVATIONS ON 
FUNCTIONAL NERVOUS DISORDERS. Second American edi- 
tion. In one octavo volume of 340 pages. Cloth, $3.25. 

JULER (HENRY). A HANDBOOK OF OPHTHALMIC SCIENCE 

AND PRACTICE. Second edition. In one octavo volume of 549 

?ages, with 201 engravings. 17 chromo-lithographic plates, test-types of 
aeeer and Snellen, and Holmgren's Color-Blindness Test. Cloth, 
$5.50 ; leather, $6.50. 



The continuous approval mani- 
fested toward this work testifies to 
the success with which the author 
has produced concise descriptions 
and typical illustrations of all the 
important affections of the eye. The 
volume is particularly rich in mat- 
ter of practical value, such as direc- 
tions for diagnosing, use of instru- 
ments, testing for glasses, for color 
blindness, etc. The sections devoted 
to treatment are sinsularlv full, and 



at the same time concise, and couch- 
ed in language that cannot fail to be 
understood. This edition likewise 
embodies such revisions and changes 
as were necessary to render it thor- 
ouehly representative, and moreover 
it has been enriched by the addition 
of 100 pages and 75 engravings. All 
told, there are 201 engravings, ex- 
elusive of 17 handsomely colored. — 
The Jledical Age. 



KING LA. F. A.). A MANUAL 
In one 12mo. vol. of 532 pages, wi 

It is just such a work as the obstet- 
rician turns to in time of need with 
the assurance that he will in a mo- 
ment refresh his memory on the sub- 
ject. A vast amount of knowledge 
is expressed in small space. — The 
Ohio Medical Journal. 

This is undoubtedly the best man- 
ual of obstetrics. Six editions in 
thirteen years show not only a de- 
mand for a book of this kind, but 
that this particular one meets the 
requirements for popularity, being 
clear, concise and practical. The 
present edition has been carefully 
revised, and a number of additions 



OF OBSTETRICS. Sixth edition. 

th 221 illus. Cloth, $2.50. 
and modifications have been intro- 
duced to bring the book to date. It 
is well illustrated, well arranged ; 
in short, a model manual. — The Chi- 
caqo Medical Recorder. 
For clearness of diction it is not 

i excelled by any book of similar na- 
ture, and by its system of captions 
and italics it is abundantly suited to 
the needs of the medical student. 

! The book is undoubtedly the best 
manual of obstetrics extant in Eng- 
lish. — The Philadelphia Polyclinic. 
The most valuable manual for stu- 

t dents that is published. — Xational 
Jled. Review. 



KIRK (EDWARD CM. OPERATIVE DENTISTRY. Handsome 
octavo of 700 passes, with 751 illustrations. Just ready. See American 
Books of Dentistry, -page 2. 

The work is essentially a new departure. Since the subject was last 
treated in text -book form the high specialization devoted to it has resulted 
in a development beyond the power of any single mind to represent. 
Accordingly Professor Kirk has secured the assistance of gentlemen of 
recognized authority in the various departments, and as a result the 
student now has at command the best and most modern knowledge pre- 
sented in the form which facilitates to the utmost its assimilation. 



18 Lea Brothers & Co., Philadelphia and New York. 

KLEIN (E.). ELEMENTS OF HISTOLOGY. Fourth edition. In 
one pocket-size 12mo. volume of 376 pages, with 194 engravings. 
Cloth, $1.75. See Student's Series of Manuals, page 27. 



It is the most complete and con- 
cise work of the kind that has yet 
emanated from the press, and is 
invaluable to the active as well as 
to the embryo practitioner. The 
illustrations are vastly superior to 
those in most works of its class. — 
The Medical Age. 

The clear and concise manner in 



which it is written, the absence of 
debatable matter, and of conflicting 
views, the convenient size of the 
book and its moderate price, will 
account for its undoubted success. — 
Medical Chronicle. 

This work deservedly occupies a 
first place as a text-book on his- 
tology. — Canadian Practitioner. 



L.ANDIS (HENRY G.). THE MANAGEMENT OF LABOR. In one 

handsome 12mo. volume of 329 pages, with 28 illus. Cloth, $1.75. 

LA ROCHE (R). YELLOW FEVER. In two 8vo. volumes of 1468 

pages. Cloth, $7. 
PNEUMONIA. In one 8vo. volume of 490 pages. Cloth, $3. 

LAURENCE (J. Z.) AND MOON (ROBERT C). A HANDY- 
BOOK OF OPHTHALMIC SURGERY. Second edition. In one 
octavo volume of 227 pages, with 66 engravings. Cloth, $2.75. 

LAWSON (GEORGE). INJURIES OF THE EYE, ORBIT AND 
EYE-LIDS. From the last English edition. In one handsome octavo 
volume of 404 pages, with 92 engravings. Cloth, $3.50. 

LEA (HENRY C). A HISTORY OF AURICULAR CONFESSION 
AND INDULGENCES IN THE LATIN CHURCH. In three 
octavo volumes of about 500 pages each. Per volume, cloth, $3.00. 
Complete work just ready. 

CHAPTERS FROM THE RELIGIOUS HISTORY OF SPAIN 

CENSORSHIP OF THE PRESS; MYSTICS AND ILLUMIN ATI 
THE ENDEMONIADAS ; EL SANTO NINO DE LA GUARDIA 
BRIANDA DE BARDAXI. In one 12mo. volume of 522 pages 
Cloth, $2.50. 

FORMULARY OF THE PAPAL PENITENTIARY. In one 

octavo volume of 221 pages, with frontispiece. Cloth, $2.50. 

SUPERSTITION AND FORCE ; ESSAYS ON THE WAGER 

OF LAW, THE WAGER OF BATTLE, THE ORDEAL AND 
TORTURE. Fourth edition, thoroughlv revised. In one hand- 
some royal 12mo. volume of 629 pages. Cloth, $2.75. 

STUDIES IN CHURCH HISTORY. The Rise of the Temporal 

Power — Benefit of Clergy — Excommunication. New edition. In one 
handsome 12mo. volume of 605 pages. Cloth, $2.50. 

AN HISTORICAL SKETCH OF SACERDOTAL CELIBACY 

IN THE CHRISTIAN CHURCH. Second edition. In one hand- 
some octavo volume of 685 pages. Cloth, $4.50. 

LEE (HENRY) ON SYPHILIS. In one 8vo. volume of 246 pages. 
Cloth, $2.25. 

LEHMANN (C. G.). A MANUAL OF CHEMICAL PHYSIOLOGY. 

In one 8vo. volume of 327 pages, with 41 engravings. Cloth, $2.25. 

LEISHMAN (WILLIAM). A SYSTEM OF MIDWIFERY. Includ- 
ing the Diseases of Pregnancy and the Puerperal State. Fourth edi- 
tion. In one octavo volume. 



Lea Beothees & Co., Philadelphia and New Yoek. 19 



LOOMIS (ALFRED L.) AND THOMPSON ("W. GDLMAN, 

EDITORS). A SYSTEM OF PEACTICAL MEDICINE. In 
Contributions by Various American Authors. ' In four very hand- 
some octavo volumes of about 900 pages each, fully illustrated in 
black and colors. Vols. I. and II., just ready. Vols. III. and IV., 
in active preparation. Per volume, cloth, $5 ; leather, $6 ; half 
Morocco, $7. For sale by. subscription only. Full prospectus free 
on application to the Publishers. See American System of Practical 
Medicine, page 2. 



LUDLOW (J. L.). A MANUAL OF EXAMINATIONS UPON 
ANATOMY, PHYSIOLOGY, SURGERY, PRACTICE OF MEDI- 
CINE, OBSTETRICS, MATERIA MEDICA, CHEMISTRY, PHAR- 
MACY AND THERAPEUTICS. To which is added a Medical For- 
mulary. Third edition. In one royal 12mo. volume of 816 pages, with 
370 engravings. Cloth, $3.25 ; leather, $3.75. 



LUFF (ARTHUR P.). 
Students of Medicine, 
engravings. Cloth, $2. 



MANUAL OF CHEMISTRY, for the use of 
In one 12mo. volume of 522 pages, with 36 
See Student's Series of Manuals, page 27. 



LYMAN (HENRY M.). THE PRACTICE OF MEDICINE. In one 

very handsome octavo volume of 925 pages, Avith 170 engravings. 
Cloth, $4.75 ; leather, $5.75. 



An excellent treatise on the prac- 
tice of medicine, written by one 
who is not only familiar with his 
subject, but who has also learned 
through practical experience in 
teaching what are the needs of the 
student and how to present the facts 
to his mind in the most readily 
assimilable form. The practical and 
busy physician, who wants to ascer- 
tain in a short time all the necessary 
facts concerning the pathology or 



treatment of any disease will find 
here a safe and convenient guide. — 
The Charlotte Medical Journal. 

Complete, concise, fully abreast of 
the times and needed by all students 
and practitioners. — Univ. Med. Mag. 

Au exceedingly valuable text-book. 
Practical, systematic, complete and 
well balanced. — Chicago Med. Re- 
corder. 

Represents fully the most recent 
knowledge. — Montreal Med. Jour. 



LYONS (ROBERT D.). A TREATISE ON FEVER, 
volume of 362 pages. Cloth, $2.25. 



In one octavo 



MA1SCH (JOHN M.). A MANUAL OF ORGANIC MATERIA 

MEDICA. New (6th) edition, thoroughly revised by H. C. C. Maisch, 
Ph. G., Ph. D. In one veiy handsome 12mo. volume of 509 pages, with 
285 engravings. Cloth. $3. 



The best handbook upon phar- 
macognosy of any published in this 
country. — Boston Med. c0 Sur. Jour. 

Noted on both sides of the Atlantic 
and esteemed as much in Germany as 
in America. The work has no equal. 
— Dominion Med. Monthly. 

Used as text-book in every college 
of pharmacy in the United States 
and recommended in medical col- 
-American Therapist, 



New matter has been added, and 
the whole work has received careful 
revision, so as to conform to the new 
United States Pharmacopoeia. — Vir- 
ginia Medical Monthly. 

This standard text-book is a 
work of such well-tried merit that it 
stands in no danger of being super- 
seded. — Amer. Druggist and Pharm, 
Record. 



20 Lea Brothers & Co., Philadelphia and New York. 

MANUALS. See Student's Quiz Series, page 27, Student's Series of 
Manuals, page 27, and Series of Clinical Manuals, page 25. 

MARSH (HOWARD). DISEASES OF THE JOINTS. In one 12mo. 
volume of 468 pages, with 64 engravings and a colored plate. Cloth, $2. 
See Series of Clinical Manuals, page 25. 

MAY (C. H.). MANUAL OF THE DISEASES OF WOMEN. For 

the use of Students and Practitioners. Second edition, revised by L. 
S. Ratt, M. D. In one 12mo. volume of 360 pages, with 31 engrav- 
ings. Cloth, $1.75. 



MITCHELL (S. WEIR). CLINICAL LESSONS ON NERVOUS 
DISEASES. In one 12mo. volume of 299 pages, with 19 engravings 
and 2 colored plates. Just ready. Cloth, $2.50. Of the hundred 
numbered copies with the Author's signed title page a few remain ; 
these are offered in green cloth, gilt top, at $3.50, net. 



There is no question as to the in- 
terest of the clinical pictures pre- 
sented in this volume. Many rare 
examples of spurious troubles 
(hysteria) are given and irregular 
types of other "nervous " affections. 
The study of these types, from the 
author's clear notes and deductions, 
will be of value to the student of 
neurology.— The Chicago Clinical 
Review. 

This is a book by a master and if 
we mistake not it will prove a very 



popular one. The book treats of 
hysteria, recurrent melancholia, dis- 
orders of sleep, choreic movements, 
false sensations of cold, ataxia, 
hemiplegic pain, treatment of sci- 
atica, erythromelalgia, reflex ocular 
neurosis, hysteric contractions, ro- 
tary movements in the feeble 
minded, etc. Few can speak with 
more authority than the author. — 
The Journal of the American Medi- 
cal Association. 



MITCHELL (JOHN K.). REMOTE CONSEQUENCES OF IN- 
JURIES OF NERVES AND THEIR TREATMENT. In one 

handsome 12mo. volume of 239 pages, with 12 illustrations. Cloth, $1.75. 



Injuries of the nerves are of fre- 
quent occurrence in private practice, 
and often the cause of intractable 
and painful conditions, conse- 
quently this volume is of especial 
interest. Doctor Mitchell has had 
access to hospital records for the last 
thirty years, as well as to the 



government documents, and has 
skilfully utilized his opportunities. 
This work will doubtless take a 
prominent place in medical litera- 
ture among the special monographs 
which throw light into obscure 
places and contribute to the advance 
of medical science. — The Med. Age. 



MORRIS (HENRY). SURGICAL DISEASES OF THE KIDNEY. 

In one 12mo. volume of 554 pages, with 40 engravings and 6 colored 
plates. Cloth, $2.25. See Series of Clinical 31anuals, page 25. 



MORRIS (MALCOLM). DISEASES OF THE SKIN. In one 

square 8vo. volume of 572 pages, with 19 chromo-lithographic figures 
and 17 engravings. Cloth, $3.50. 

MULLER (J.). PRINCIPLES OF PHYSICS AND METEOROL- 
OGY. In one large 8vo. vol. of 623 pages, with 538 cuts. Cloth, $4.50. 



Lea Bkothees & Co.. Philadelphia axi> Nbw Yoke:. 21 



MUSSER JOHN H. . A PRACTICAL TREATISE ON MEDICAL 
DIAGNOSIS, for Students and Physicians. 2s ew 2d edition, thor- 
oughly revised. In one octavo volume of 3 s with 177 engi v- 

ings and 11 full-page colored plates. Cloth. $-5 ; leather. $6. Just 
ready. 

"We have no work of equal value with only hy the specialist. The 



iu English. — University M 
Magazine. 

Every real advance that has been 
made in this rapidly progressing 
department of medicine is here re- 
corded. There is no half knowledge. 
His descriptions of the diagnostic 
manifestations of diseases are accu- 
rate. This work will meet all the 
requirements of student and physi- 
cian. — The Medical yews. 

Erom its pages may be made the 
diagnosis of everv maladv that 



early demand for the new edition 
speaks volumes for the book's popu- 
larity. — North wester ■ L 

It so thoroughly meets the precise 
demands incident to modern research 
that it has been already adopted as a 
leading text-hook by' the medical 
colleges of this country. — North 
American Practitioner. - 

Occupies the foremost plat 
thorough, systematic treatise.— Oh io 
Me d lea I Jo ur nal. 

The best of its kind, invaluable to 



afflicts the human body, including the student, general practitioner and 
those which in general are dealt teacher. — M. Meal Journal. 



NATIONAL DISPENSATORY. See Stille, Maiseh & Caspari. p. 27. 

NATIONAL FORMULARY. See Stille, Maiseh & C v atonal 

Dispensatory, page 27. 

NATIONAL MEDICAL DICTIONARY. See Billings, page 4. 



NETTLESHTP E. . DISEASES OE THE EYE. Fourth American 
from fifth English edition. In 'me 12mo. volume of 500 pages, 
with 164 engravings, test-types and formula? and color-blindness test. 

Cloth, .>: 

Four large American editions 
testify to thefact that it is a favorite 
text-book in American coIIt. 
well as to the extent of its use 
among practitioners in general and 
special branches. Its popularity as 
a reference-book is due to the prac- 



tical nature of its text and to the 
inclusion of test-types, color-blind- 
ness tests and a collection of 
formula?. It is safe to predict that 
this handy volume will become more 
than ever a favorite with all classes 
of readers. — Pacifie Med. Journal. 



NORRIS \VM. F. AND OLIVER CHAS. A. . TEXT BOOK OF 
OPHTHALMOLOGY. In one octavo volume of 641 pages, with 357 
engraving.- and 5 colored plates. Cloth. $o : leather. 



We take pleasure in commending 
the "Text-book" to students and 
practitioners as a safe and admir- 
able guide, well qualified to furnish 
them~ as the authors intended it 
should, with •'" a working knowl- 
edge of ophthalmology."' — Johns 
Hopkins Hospital Bulletin. 

The first text-book of diseases of 
the eye written by American authors 
for American colleges and students. 
Every method of ocular precision 
that can be of any clinical advantage 



to the eveiy-day student and the 
scientific observer is offered to the 
reader. Rules and procedures are 

made so plain and so evident, that 
any student can easily understand 
and employ them. It is j^ractical in 
its teachings. "SVe unreservedly en- 
dorse it as the best, the safest and the 
most comprehensive volume upon 
the subject that has . offered 

to the American medical public. — 
Annals of Ophthalmology and Oto- 
logy. 



22 Lea Bbothees & Co., Philadelphia and New Yoek. 



OWEN (EDMUND). SUKGICAL DISEASES OF CHILDREN. 

In one 12mo. volume of 525 pages, with 85 engravings and 4 colored 
plates. Cloth, $2. See Series of Clinical Manuals, page 25. 



PARK (ROSWELL). A TREATISE ON SURGERY BY AMERI- 
CAN AUTHORS. In two handsome octavo volumes. Volume I., 
General Surgeiy, 799 pages, with 356 engravings and 21 full-page 
plates, in colors and monochrome. Volume II., Special Surgery, 
800 pages, with 430 engravings and 17 full-page plates, in colors 
and monochrome. Per volume, cloth, $4.50; leather, $5.50. Net. 
Complete work just ready. 



The work is fresh, clear and practi- 
cal, covering the ground thoroughly 
yet briefly, and well arranged for 
rapid reference, so that it will be of 
special value to the student and busy 
practitioner. The pathology is 
broad, clear and scientific, while the 
suggestions upon treatment are 
clear-cut, thoroughly modern and 
admirably resourceful. — Johns Hop- 
kins Hospital Bulletin. 

The latest and best work written 
upon the science and art of surgery. 
Columbus Medical Journal. 

Its special field of application is 
in practical, every-day use. It well 
deserves a place in every medical 
man's library. — The Pittsburg Med- 
ical Review. 

The illustrations are almost en- 



tirely new and executed in such a 
way that they add great force to the 
text. It gives us unusual pleasure 
to recommend this work to students 
and practitioners alike. — The Chi- 
cago Medical Recorder. 

The various writers have em- 
bodied the teachings accepted at 
the present hour and the methods 
now in vogue, both as regards 
causes and treatment. — The North 
American Practitioner. 

Both for the student and practi- 
tioner it is most valuable. It is 
thoroughly practical and yet thor- 
oughly scientific. — Medical News. 

A truly modern surgery, not only 
in pathology, but also in sound 
surgical therapeutics. — New Or- 
leans Med. and Surgical Journal. 



PARRY (JOHN S.). EXTRA-UTERINE PREGNANCY, ITS 
CLINICAL HISTORY, DIAGNOSIS, PROGNOSIS AND TREAT- 
MENT. In one octavo volume of 272 pages. Cloth, $2.50. 



PARVEV (THEOPHTLUS). THE SCIENCE AND ART OF OB- 
STETRICS. Third edition. In one handsome octavo volume of 
677 pages, with 267 engravings and 2 colored plates. Cloth, $4.25 ; 
leather, $5.25. 



In the foremost rank among the 
most practical and scientific medical 
works of the day. — Medical News. 

It ranks second to none in the 
English language. — Annals of Gyne- 
cology and Pediatry. 

The book is complete in eveiy de- 
partment, and contains all the neces- 
sary detail required by the modern 
practising obstetrician. — Interna- 
tional Medical Magazine. 

In breadth and scope the work is 
adapted to the needs of the advanced 
scholar and specialist. The con- 



sideration of every subject is in 
reality brought up to the hour when 
the copy went to print. — Medicine. 

Parvin's work is practical, con- 
cise and comprehensive. We com- 
mend it as first of its class in the 
English language. — Medical Fort- 
nightly. 

Parvin's classical work now oc- 
cupies the front rank of modern 
text-books. It is an admirable text- 
book in every sense of the word. — 
Nashville Journal of Medicine and 
Surgery. 



PAVY (F. W.). A TREATISE ON THE FUNCTION OF DIGES- 
TION, ITS DISORDERS AND THEIR TREATMENT. From the 
second London edition. In one 8vo. volume of 238 pages. Cloth, $2. 



Lea Beothees & Co., Philadelphia and New Yoek. 23 



PAYNE (JOSEPH FRANK). A MANUAL OF GENERAL 

PATHOLOGY. Designed as an Introduction to the Practice of Medi- 
cine. In one octavo volume of 524 pages, with 153 engravings and 
1 colored plate. 

PEPPER'S SYSTEM OF MEDICINE. See page 3. 

PEPPER (A. J.). FORENSIC MEDICINE. In press. See Student's 

Series of Manuals, page 27. 
SURGICAL PATHOLOGY. In one 12mo. volume of 511 pages, 

with 81 engravings. Cloth, $2. See Student's Series of Manuals, p. 27. 

PICK (T. PICKERING). FRACTURES AND DISLOCATIONS. 

In one 12mo. volume of 530 pages, with 93 engravings. Cloth, $2. 
See Series of Clinical Manuals, page 25. 

PIRRIE (WILLIAM). THE PRINCIPLES AND PRACTICE OF 

SURGERY. In one octavo volume of 780 pages, with 316 engravings. 
Cloth, $3.75. 

PLAYFAIR (W. S.). A TREATISE ON THE SCIENCE AND 
PRACTICE OF MIDWIFERY. Sixth American from the eighth 
English edition. Edited, with additions, by R. P. Haeeis, M. D. 
In one octavo volume of 697 pages, with 217 engravings and 5 plates. 
Cloth, $4 ; leather, $5. 

In the numerous editions which 
have appeared it has been kept con- 
stantly in the foremost rank. It is 
a work which can be conscientiously 
recommended to the profession. — 
The Albany Medical Annals. 

This work must occupy a fore- 1 bodies all recent advances. — ■ The 
most place in obstetric medicine as Medical Fortnightly. 
a safe guide to both student and ' 



obstetrician. It holds a place among 
the ablest English-speaking authori- 
ties on the obstetric art. — Buffalo 
Medical and Surgical Journal. 

An epitome of the science and 
practice of midwifery, which em- 



PL AYF AIR (W. S.). THE SYSTEMATIC TREATMENT OF 
NERVE PROSTRATION AND HYSTERIA. In one 12mo. vol- 
ume of 97 pages. Cloth, $1. 

POLITZER (ADAM). A TEXT-BOOK OF THE DISEASES OF THE 
EAR AND ADJACENT ORGANS. Second American from the 
third German edition. Translated by Oscae Dodd, M. D., and 
edited by Sie William Dalby, F. R. C. S. In one octavo volume of 
748 pages, with 330 original engravings. Cloth, $5.50. 

The anatomy and physiology of i ment are clear and reliable. We 
each part of the organ of hearing can confidently recommend it, for it 
are carefully considered, and then contains all that is known upon the 
follows an enumeration of the dis- subject. — London Lancet. 
eases to which that special part of A safe and elaborate guide into 
the auditory apparatus is especially every part of otology. — American 
liable. The indications for treat- 1 Journal of the Medical Sciences. 

POWER (HENRY). HUMAN PHYSIOLOGY. Second edition. In 
one 12mo. volume of 396 pages, with 47 engravings. Cloth, $1.50. 
See Student's Series of Manuals, page 27. 

PURDY (CHARLES W.). BRIGHT'S DISEASE AND ALLIED 
AFFECTIONS OF THE KIDNEY. In one octavo volume of 288 
pages, with 18 engravings. Cloth, $2. 



24 Lea Beothees & Co., Philadelphia and New Yoek. 

PYE-SMITH (PHILIP H.). DISEASES OF THE SKIN. In one 

12mo. vol. of 407 pp., with 28 illus., 18 of which are colored. Cloth, $2. 

QUIZ SERIES. See Student's Quiz Series, page 27. 

RALFE (CHARLES H.). CLINICAL CHEMISTRY. In one 

12mo. volume of 314 pages, with 16 engravings. Cloth, $1.50. See 
Student's Series of Manuals, page 27. 

RAMSBOTHAM (FRANCIS H.). THE PRINCIPLES AND PRAC- 
TICE OF OBSTETRIC MEDICINE AND SURGERY. In one 
imperial octavo volume of 640 pages, with 64 plates and numerous 
engravings in the text. Strongly bound in leather, $7. 

REICHERT (EDWARD T.). A TEXT-BOOK ON PHYSIOLOGY. 

In one handsome octavo volume of about 800 pages, richly illustrated. 
Preparing. 

REMSEN (IRA). THE PRINCIPLES OF THEORETICAL CHEM- 
ISTRY. New (5th) edition, thoroughly revised. In one 12mo. vol- 
ume of 326 pages. Cloth, $2. Just ready. 



A. clear and concise explanation 
of a difficult subject. We cordially 
recommend it. — The London Lancet. 

The book is equally adapted to the 
student of chemistry or the practi- 
tioner who desires to broaden his 
theoretical knowledge of chemistry. 
— New Orleans Med. and Surg. Jour. 

The appearance of a fifth edition 
of this treatise is in itself a guarantee 



that the work has met with general 
favor. This is further established 
by the fact that it has been trans- 
lated into German and Italian. The 
treatise is especially adapted to the 
laboratory student. It ranks unusu- 
ally high among the works of this 
class. This edition has been brought 
fully up to the times. — American 
Medico- Surgical Bulletin. 



REYNOLDS (J. RUSSELL). A SYSTEM OF MEDICINE. Ed- 
ited, with notes and additions, by Henry Hartshorne, M. D. In 
three large 8vo. vols., containing 3056 closely printed double-columned 
pages, with 317 engravings. Per volume, cloth, $5 ; leather, $6. For 
sale by subscription only. 

RICHARDSON (BENJAMIN WARD). PREVENTIVE MEDI- 
CINE. In one octavo volume of 729 pages. Cloth, $4 ; leather, $5. 

ROBERTS (JOHN B.). THE PRINCIPLES AND PRACTICE OF 
MODERN SURGERY. In one octavo volume of 780 pages, with 
501 engravings. Cloth, $4.50 ; leather, $5.50. 

THE COMPEND OF ANATOMY. For use in the Dissecting 



Room and in preparing for Examinations. In one 16mo. volume of 
196 pages. Limp cloth, 75 cents. 

ROBERTS (SIR WILLIAM). A PRACTICAL TREATISE ON 
URINARY AND RENAL DISEASES, INCLUDING URINARY 
DEPOSITS. Fourth American from the fourth London edition. In 
one very handsome 8vo. vol. of 609 pp., with 81 illus. Cloth, $3.50. 

ROBERTSON" (J. MCGREGOR). PHYSIOLOGICAL PHYSICS. 

In one 12mo. volume of 537 pages, with 219 engravings. Cloth, $2. 
See Student's Series of Manuals, page 27. 

ROSS (JAMES). A HANDBOOK OF THE DISEASES OF THE 
NERVOUS SYSTEM. In one handsome octavo volume of 726 pages, 
with 184 engravings. Cloth, $4.50 ; leather, $5.50. 

SAVAGE (GEORGE H.). INSANITY AND ALLIED NEUROSES, 
PRACTICAL AND CLINICAL. In one 12mo. volume of 551 pages, 
with 18 typical engravings. Cloth, $2. See Series of Clinical Man- 
uals, page 25. 



Lea Brothers & Co., Philadelphia and New York. 25 

SCHAFER (EDWARD A.). THE ESSENTIALS OF HISTOL- 
OGY, DESCRIPTIVE AND PRACTICAL. For the use of Students. 
New (4th) edition. In one handsome octavo volume of 311 pages, 
with 325 illustrations. Cloth, $3. 

Nowhere else will the same very I The most satisfactory elementary 
moderate outlay secure as thoroughly i text-book of histology in the Eng- 
useful and interesting an atlas of | lish language. — The Boston Med. and 
structural anatomy. — The American Sur. Jour. 
Journal of the Medical Sciences. 

A COURSE OF PRACTICAL HISTOLOGY. New (2d) edition. 

In one 12mo. volume of 307 pages, with 59 engravings. Cloth, $2.25. 
Just ready. 

SCHMITZ AND ZUMPT'S CLASSICAL. SERIES. 

ADVANCED LATIN EXERCISES. Cloth, 60 cts.; half bound, 70 cts. 
SCHMIDT'S ELEMENTARY LATIN EXERCISES. Cloth, 50 cents. 
SALLUST. Cloth, 60 cents ; half bound, 70 cents. 
NEPOS. Cloth, 60 cents ; half bound, 70 cents. 
VIRGIL. Cloth, 85 cents; half bound, $1. 
CURTIUS. Cloth, 80 cents; half bound, 90 cents. 

SCHOFD3LD (ALFRED T.). ELEMENTARY PHYSIOLOGY 

FOR STUDENTS. In one 12mo. volume of 380 pages, with 227 
engravings and 2 colored plates. Cloth, $2. 

SCHRED3ER (JOSEPH). A MANUAL OF TREATMENT BY 
MASSAGE AND METHODICAL MUSCLE EXERCISE. Trans- 
lated by Walter Mendelson, M. D., of New York. In one hand- 
some octavo volume of 274 pages, with 117 fine engravings. 

SENN (NICHOLAS). SURGICAL BACTERIOLOGY. Second edi- 
tion. In one octavo volume of 268 pages, with 13 plates, 10 of which 
are colored, and 9 engravings. Cloth, $2. 

SERIES OF CLINICAL MANUALS. A Series of Authoritative 
Monographs on Important Clinical Subjects, in 12mo. volumes of about 
550 pages, well illustrated. The following volumes are now ready : 
Broadbent on the Pulse, $1.75; Yeo on Food in Health and Disease, 
new (2d) edition, $2.50; Carter and Frost's Ophthalmic Surgery, 
$2.25 ; Hutchinson on Syphilis, $2.25 ; Marsh on Diseases of the 
Joints, $2; MORRIS on Surgical Diseases of the Kidney, $2.25; Owes 
on Surgical Diseases of Children, $2; Pick on Fractures and Dis- 
locations, $2; Btjtlin on the Tongue, $3.50; Savage on Insanity and 
Allied Neuroses, $2 ; and Treves on Intestinal Obstruction, $2. The 
following is in press : Lucas on Diseases of the Urethra. 
For separate notices, see under various authors' names. 

SERIES OF STUDENT'S MANUALS. See page 27. 

SIMON (CHARLES E.). CLINICAL DIAGNOSIS, BY MICRO- 
SCOPICAL AND CHEMICAL METHODS. In one very handsome 
octavo volume, of 504 pages, with 132 engravings and 10 fnll-page 
colored plates. Cloth, $3.50. Just ready. 
This is a very much-needed book, in the full detail of the technique as 
A most excellent arrangement con- to mode of securing, preparing and 
sistsin the Differential Table of the examining specimens. — The Yir- 
More Important Diseases, or of the ginia Med. Semi-Monthly . 
fluid, secretion or excretion, under Will adequately supply a well-re- 
consideration — the table being at the cognized deficiency. — British Med. 
end of each subject discussed. An- Journal. 
other excellence of the book consists I 



26 Lea Brothers & Co., Philadelphia and New York. 



SIMON (W.). MANUAL OF CHEMISTRY. A Guide to Lectures 
and Laboratory Work for Beginners in Chemistry. A Text-book 
specially adapted for Students of Pharmacy and Medicine. Fifth 
edition. In one 8vo. volume of 501 pages, with 44 engravings and 8 
plates showing colors of 64 tests. Cloth, $3.25. Just ready. 



the covers of this book. — The North- 
western Lancet. 

Its statements are all clear and its 
teachings are practical. — Virginia 
Med. Monthly. 

SL.ADE (D. D.). DIPHTHERIA; ITS NATURE AND TREAT- 
MENT. Second edition. In one royal 12mo. vol., 158 pp. Cloth, $1.25. 



It is difficult to see how a better 
book could be constructed. No man 
who devotes himself to the practice 
of medicine need know more about 
chemistry than is contained between 



SMITH (EDWARD). 

DIABLE STAGES. 



CONSUMPTION; ITS EARLY AND REME- 

In one 8vo. volume of 253 pp. Cloth, $2.25. 



SMITH (J. LEWIS). A TREATISE ON THE DISEASES OF IN- 
FANCY AND CHILDHOOD. New (8th) edition, thoroughly revised 
and rewritten and much enlarged. In one large 8vo. volume of 983 
pages, with 273 engravings and 4 full-page plates. Cloth, $4.50; 
leather, $5.50. 



The most complete and satisfac- 
tory text-book with which we are 
acquainted. —American Gynecologi- 
cal and Obstetrical Journal. 

It truly is the most evenly bal- 
anced, clear in description and 
thorough in detail of any of the 
books published in this country on 
this subject. — Medical Fortnightly. 

A treatise which in every respect 



can more than hold its own against 
any other work treating of the same 
subject. — American Medico-Surgical 
Bulletin. 

A safe guide for students and phy- 
sicians. — The Am. Jour, of Obstetrics. 

For years the leading text-book on 
children's diseases in America. — 
Chicago Medical Recorder. 



SMITH (STEPHEN). OPERATIVE SURGERY. Second and thor- 
oughly revised edition. In one octavo volume of 892 pages, with 
1005 engravings. Cloth, $4 ; leather, $5. 



dium for the modern surgeon. — Bos- 
ton Medical and Surgical Journal. 



One of the most satisfactory works 
on modern operative surgery yet 
published. The book is a compen- 

SOLL.Y (S. EDWIN). A HANDBOOK OF MEDICAL CLIMA- 
TOLOGY. In one handsome octavo volume of 462 pages, with en- 
gravings and 11 full-page plates, 5 of which are in colors. Cloth, $4.00. 
Just ready. 



A clear and lucid summary of 
what is known of climate in relation 
to its influence upon human beings. 
— The Therapeutic Gazette. 

The book is admirably planned, 
clearly written,and the author speaks 
from an experience of thirty years as 



an accurate observer and practical 
therapeutist.— -Maryland Med. Jour. 
Every practitioner of medicine 
should possess himself of a copy and 
study it, and we are sure he will 
never regret it.— St. Louis Medical 
and Surgical Journal. 



STDLLE (ALFRED). CHOLERA; ITS ORIGIN, HISTORY, CAUS- 
ATION, SYMPTOMS, LESIONS, PREVENTION AND TREAT- 
MENT. In one 12mo. volume of 163 pages, with a chart showing 
routes of previous epidemics. Cloth, $1.25. 

THERAPEUTICS AND MATERIA MEDICA. Fourth and 

revised edition. In two octavo volumes, containing 1936 pages. 
Cloth, $10; leather, $12. 



Lea Brothers & Co., Philadelphia and New York. 27 



STILLE (ALFRED), MAISCH (JOHN M.) AND CASPARI 
(CHAS. JR.). THE NATIONAL DISPENSATORY: Containing 
the Natural History, Chemistry, Pharmacy, Actions and Uses of 
Medicines, including those recognized in the latest Pharmacopoeias of 
the United States, Great Britain and Germany, with numerous refer- 
ences to the French Codex. Fifth edition, revised and enlarged, 
including the new U. S. Pharmacopoeia, Seventh Decennial Revision. 
With Supplement containing the new edition of the National Formu- 
lary. In one magnificent imperial octavo volume of about 2025 pages. 



with 320 engravings. 
Thumb-letter Index. 



Cloth, $7.25 ; leather, $8. With ready reference 
Cloth, $7.75 ; leather, $8.50. 



Recommended most highly for the 
physician, and invaluable to the 
druggist. — Therapeutic Gazette. 

It is the official guide for the Med- 
ical and Pharmaceutical professions. 
— Buffalo Med. and Sur. Jour. 

The readiness with which the vast 



amount of information contained in 
this work is made available is indi- 
cated by the twenty-five thousand 
references in the two indexes. — Bos- 
ton Medical and Surgical Journal. 
Should be recognized as a national 
standard. — North Am. Practitioner. 



STIMSON (LEWIS A.). A MANUAL OF OPERATIVE SURGERY. 
New (3d) edition. In one royal 12mo. volume of 614 pages, with 306 
engravings. Cloth, $3.75. Just ready. 



A useful and practical guide for 
all students and practitioners. — Am. 
Journal of the Medical Sciences. 



The book is worth the price for the 
illustrations alone. — Ohio Medical 
Journal. 



STIMSON (LEWIS A.). A TREATISE ON FRACTURES AND 
DISLOCATIONS. In two handsome octavo volumes. Vol. I., Frac- 
tures, 582 pages, 360 engravings. Vol. II., Dislocations, 540 
pages, 163 engravings. Complete work, cloth, $5.50 ; leather, $7.50. 
Either volume separately, Cloth, $3 ; leather, $4. 



STUDENT'S QUIZ SERIES. A New Series of Manuals in question aria 
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science. Thirteen volumes, pocket size, convenient, authoritative, 
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ber); 8. Genito-Urinary and Venereal Diseases ; 9. Diseases of the Skin; 
10. Diseases of the Eye, Ear, Throat and Nose; 11. Obstetrics; 12. 
Gynecology; 13. Diseases of Children. Price, $1 each, except Nos. 
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STUDENT'S SERIES OF MANUALS. A Series of Fifteen Man- 
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volumes, per set, $6; Bell's Comparative Anatomy and Physiology, $2; 
Robertson's Physiological Physics, $2 ; Gould's Surgical Diagnosis, 
$2; Klein's Elements of Histology (4th edition), $1.75; Pepper's 
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Power's Human Physiology (2d edition), $1.50 ; Ralfe's Clinical 
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$1.50. The following is in press : Pepper's Forensic Medicine. 
For separate notices, see under various author's names. 



28 Lea Brothees & Co., Philadelphia and New York. 



STURGES (OCTAVIUS). AN INTRODUCTION TO THE STUDY 
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SUTTON (JOHN BliAND). SURGICAL DISEASES OF THE 
OVAEIES AND FALLOPIAN TUBES. Including Abdominal 
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and 5 colored plates. Cloth, $3. 



— TUMORS, INNOCENT AND MALIGNANT. Their Clinical 
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250 engravings and 9 full-page plates. Cloth, $4.50. Just ready. 



TAIT (LAWSON). DISEASES OF WOMEN AND ABDOMINAL 
SURGERY. In two handsome octavo volumes. Vol. I. contains 546 
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TANNER (THOMAS HAWKES) ON THE SIGNS AND DIS- 
EASES OF PREGNANCY. From the second English edition. In 
one octavo volume of 490 pages, with 4 colored plates and 16 engrav- 
ings. Cloth, $4.25. 

TAYLOR (ALFRED S.). MEDICAL JURISPRUDENCE. New 

American from the twelfth English edition, specially revised by Clark 
Bell, Esq., of the N. Y. Bar. In one octavo volume of about 800 
pages, with about 75 engravings. Cloth, $4.50; leather, §5.50 Just recall). 

Notices of previous edition are appended. 

No library is complete without j The editor has given to two pro- 
Taylor's Medical Jurisprudence, as fessions a reference-book to be relied 



its authority is accepted and un 
questioned by the courts. — Buffalo 
Medical and Surgical Journal. 



upon. — The American Journal of the 
Medical Sciences. 



TAYLOR (ALFRED S.). ON POISONS IN RELATION TO 
MEDICINE AND MEDICAL JURISPRUDENCE. Third Ameri- 
can from the third London edition. In one octavo volume of 788 
pages, with 104 illustrations. Cloth, $5.50 ; leather, $6.50. 



TAYLOR (ROBERT TV.). THE PATHOLOGY AND TREAT- 
MENT OF VENEREAL DISEASES. In one veiy handsome octavo 
volume of 1002 pages, with 230 engravings and 7 colored plates. 
Cloth, $5.00 ; leather, $6.00. {Net.) Just ready. 



By long odds the best work on 
venereal diseases. — Louisville Medi- 
cal Monthly. 

In the observation and treatment 
of venereal diseases his experience 
has been greater probably than that 
of any other practitioner of this con- 
tinent. — Neiv York Medical Joe rnal. 

The clearest, most unbiased and 
ably presented treatise as yet pub- 
lished on this vast subject. — The 
Medical News. 

Decidedly the most important and 
authoritative treatise on venereal 
diseases that has in recent years ap- 
peared in English. — American Jour- 
nal of the Medical Sciences. 



It is a veritable storehouse of our 
knowledge of the venereal diseases. 
It is commended as a conservative, 
practical, full exposition of the 
greatest value. — Chicago Clinical 
Review. 

The best work on venereal dis- 
eases in the English language. It 
is certainly above everything of the 
kind. — The St. Louis Medical and 
Surgical Journal. 

The student or practitioner will 
find in this book a most full, com- 
plete and trustworthy guide on all 
points connected, with this subject. 
— The Montreal Medical Journal. 



Lea Beothees & Co., Philadelphia and New Yoek. 29 

TAYLOR (ROBERT W.). A PE ACTIO AL TREATISE ON SEX- 
UAL DISORDERS IN THE MALE AND FEMALE. In one 
8vo. vol. of 416 pp., with 73 engravings and 8 colored plates. Cloth, 

$3. Net. Just ready. 

A work handling sexual diseases in a scientific and practical manner. 
The same practicality which has made the author's Pathology and Treat- 
ment of Venereal Diseases the recognized authority will secure for this 
new volume equal favor. It will afford the general practitioner as well 
as the specialist the best methods of treating a very large class of cases. 

A CLINICAL ATLAS OF VENEREAL AND SKIN DISEASES. 



Including Diagnosis, Prognosis and Treatment. In eight large folio 
parts, measuring 14 x 18 inches, and comprising 213 beautiful figures 
on 58 full-page chromo-lithographic plates, 85 fine engravings and 425 
pages of text. Complete work now ready. Price per part, sewed in 
heavy embossed paper, $2.50. Bound in one volume, balf Russia, 
$27 ; half Turkey Morocco, $28. For sale by subscription only. Address 
the publishers. Specimen plates by mail on receipt of ten cents. 

TAYLOR (SEYMOUR). INDEX OF MEDICINE. A Manual for 
the use of Senior Students and others. In one large 12mo. volume of 
802 pages. Cloth, $3.75. 

THOMAS (T. GAILLARD) AND MUNDE (PAUL F.). A PRAC- 
TICAL TREATISE ON THE DISEASES OF WOMEN. Sixth 
edition, thoroughly revised by Paul F. Munde, M. D. In one 
large and handsome octavo volume of 824 pages, with 347 engravings. 
Cloth, $5 ; leather, $6. 



The best practical treatise on the 
subject in the English language. 
It will be of especial value to the 
general practitioner as well as to the 
specialist. The illustrations are very 
satisfactory. Many of them are new 
and are particularly clear and attrac- 
tive. — Boston Med. and Sur. Jour. 



This work, which has already gone 
through five large editions, and has 
been translated into French, Ger- 
man, Spanish tmd Italian, is the 
most practical and at the same time 
the most complete treatise upon the 
subject. — The Archives of Gynecol- 
ogy, Obstetrics and Pediatrics. 



THOMPSON (SIR HENRY). CLINICAL LECTURES ON DIS- 
EASES OF THE URINARY ORGANS. Second and revised edi- 
tion. In one octavo vol. of 203 pp., with 25 engravings. Cloth, $2.25. 

THE PATHOLOGY AND TREATMENT OF STRICTURE 



OF THE URETHRA AND URINARY FISTULA. From the 
third English edition. In one octavo volume of 359 pages, with 47 
engravings and 3 lithographic plates. Cloth, $3.50. 

TODD (ROBERT BENTLEY). CLINICAL LECTURES ON CER- 
TAIN ACUTE DISEASES. In one 8vo. vol. of 320 pp., cloth, $2.50. 

TREVES (FREDERICK). OPERATIVE SURGERY. In two 

8vo. vols, containing 1550 pp., with 422 illus. Cloth, $9 ; leath., $11. 

A SYSTEM OF SURGERY. In Contributions by Twenty-five 

English Surgeons. In two large octavo volumes. Vol. I., 1178 pages, 
with 463 engravings and 2 colored plates. Vol. II., 1120 pages, with 
487 engravings and 2 colored plates. Price per volume, cloth, $8. 
Complete Work just ready. 

A MANUAL OF SURGERY. In Treatises by 33 leading sur- 
geons. Three 12mo. volumes, containing 1866 pages, with 213 engrav- 
ings. Price per set, $6. See Student's Series of Manuals, page 27. 



30 Lea Brothers & Co., Philadelphia and New York. 



TREVES (FREDERICK). THE STUDENTS' HANDBOOK OF 

SURGICAL OPERATIONS. In one 12mo. volume of 50S pp., with 

94 illustrations. Cloth, $2.50. 
SURGICAL APPLIED ANATOMY. In one 12mo. vol. of 540 pp., 

with 61 engravings. Cloth, $2. See Student's Series of Manuals, p. 27. 
INTESTINAL OBSTRUCTION. In one 12mo. volume of 522 

pages, with 60 illus. Cloth, $2. See Series of Clinical Jfanuals, p. 25. 

TUKE (DANIEL HACK). THE INFLUENCE OF THE MIND 
UPON THE BODY IN HEALTH AND DISEASE. Second edition. 
In one 8vo. volume of 467 pages, with 2 colored plates. Cloth, $3. 

VAUGHAN (VICTOR C.) AND NOVY (FREDERICK G.). 

PTOMAINS, LEUCOMAINS, TOXINS AND ANTITOXINS, 
or the Chemical Factors in the Causation of Disease. New (3d) edition. 
In one 12mo. volume of 603 pages. Cloth, $3. Just ready. 
The work has been brought down I The present edition has been not 
to date, and will be found entirely , only thoroughly revised throughout 
satisfactory. — Journal of the Ameri-, hut also greatly enlarged, ample 
cam Jledical Association. consideration being given to the new 

The most exhaustive and most re- j subjects of toxins and antitoxins. — 
cent presentation, of the subject. — j Tri-State Medical Journal. 
American Jour, of the Med. Sciences. ' 

VISITING LIST. THE MEDICAL NEWS VISITING LIST for 1897. 
Four styles: Weekly (dated for 30 patients); Monthly (undated for 
120 patients per month) ; Perpetual (undated for 30 patients each 
week); and Perpetual (undated for 60 patients each week). The 60- 
patient book consists of 256 pages of assorted blanks. The first three 
styles contain 32 pages of important data, thoroughly revised, and 
160 pages of assorted blanks. Each in one volume, price, $1.25. 
With thumb-letter index for quick use, 25 cents extra. Special rates 
to advance-paying subscribers to The Medical News or The 
American Journal of the Medical Sciences, or both. See p. 32. 

WATSON (THOMAS). LECTURES ON THE PRINCIPLES AND 
PRACTICE OF PHYSIC. A new American from the fifth and 
enlarged English edition, with additions bv H. Hartshorne, M. D. 
In two large 8vo. vols, of 1840 pp., with 190 cuts. Cloth, $9 ; leather, $11. 

WELLS (J. SOELBERG). A TREATISE ON THE DISEASES OF 
THE EYE. In one large and handsome octavo volume. 

WEST (CHARLES). LECTURES ON THE DISEASES PECULIAR 
TO WOMEN. Third American from the third English edition. In 
one octavo volume of 543 pages. Cloth, $3.75 ; leather, $4.75. 

ON SOME DISORDERS OF THE NERVOUS SYSTEM IN 

CHILDHOOD. In one small 12mo. volume of 127 pages. Cloth, $1. 

WHARTON (HENRY R). MINOR SURGERY AND BANDAG- 
ING. New (3d) edition. In one 12mo. vol. of 594 pages, with 475 
engravings, many of which are photographic. Cloth, $3. Just ready. 



We know of no book which more 
thoroughly or more satisfactorily 
covers the ground of Minor Surgery 
and Bandaging. — Brooklyn Medical 
Journal. 

Well written, conveniently ar- 
ranged and amply illustrated. It 
covers the field so fully as to render 
it a valuable text-book, as well as a 



work of ready reference for sur- 
geons. — Xorth Amer. Practitioner. 
The part devoted to bandaging is 
perhaps the best exposition of the 
subject in the English language. It 
can be highly commended to the 
student, the practitioner and the 
specialist. — The Chicago Medical 
Recorder, 



Lea Brothers & Co., Philadelphia and New York. 31 



WHITLA (WILLIAM). DICTIONARY OF TREATMENT, OR 
THERAPEUTIC INDEX. Including Medical and Surgical Thera- 
peutics. In one square octavo volume of 917 pages. Cloth, $4. 

WILSON (ERASMUS). A SYSTEM OF HUMAN ANATOMY. 

A new and revised American from the last English edition. Illustrated 
with 397 engravings. In one octavo volume of 616 pages. Cloth, $4 ; 
leather, $5. 

THE STUDENT'S BOOK OF CUTANEOUS MEDICINE. In 

one 12mo. volume. Cloth, $3.50. 

WEVCKEL ON PATHOLOGY AND TREATMENT OF CHILDBED. 
Translated by James R. Chadwick, A. M., M. D. With additions 
by the Author. In one octavo volume of 484 pages. Cloth, $4. 

WOHLER'S OUTLINES OF ORGANIC CHEMISTRY. Translated 
from the eighth German edition, by Ira Remsen, M. D. In one 
12mo. volume of 550 pages. Cloth, $3. 

YEAR-BOOK OF TREATMENT FOR 1897. A Critical Review for 
Practitioners of Medicine and Surgery. In contributions by 24 well- 
known medical writers. 12mo., 488 pages. Cloth, $1.50. In combi- 
nation with The Medical News and The American Journal 
of the Medical Sciences, 75 cents. See page 32. 
To repeat the praises bestowed on the hands of a practical and recog- 
previous issues is not to do full jus- nized authority. The whole field of 
tice, as every year shows improve- medicine is in this way traversed, 
ment and advances which make the and a critical estimate formed of all 
work one of increasing utility to the that is substantial and meritorious 
physician. The work this year con- ! in recent progress. — The Physician 
sists of twenty-five chapters, each in I and Surgeon. 

YEAR-BOOKS OF TREATMENT FOR 1891, 1892, 1893 and 1896, 
similar to above. Each, cloth, $1.50. 

YEO (I. BURNEY). FOOD IN HEALTH AND DISEASE. New 

(2d) edition. In one 12mo. volume of 592 pages, with 4 engravings. 

Cloth, $2.50. Just ready. See Series of Clinical Manuals, page 26. 

work of Dr. Yeo's. The value of 
the work is not to be overestimated. 
— Neiv York Medical Journal. 



We doubt whether any book on 
dietetics has been of greater or more 
widespread usefulness than has this 
much-quoted and much-consulted 



A MANUAL OF MEDICAL TREATMENT, OR CLINICAL 

THERAPEUTICS. Two volumes containing 1275 pages. Cloth, $5.50. 

YOUNG (JAMES K.). ORTHOPEDIC SURGERY. In one 8vo. 
volume of 475 pages, with 286 illustrations. Cloth, $4; leather, $5. 

In studying the different chapters, I surgical specialty and every page 
one is impressed with the thorough- \ abounds with evidences of prac- 
ness of the work. The illustrations j ticality. It is the clearest and most 
are numerous — the book thoroughly i modern work upon this growing de- 
practical — Medical Neivs. partment of surgery. — The Chicago 

It is a thorough, a very compre- ! Clinical Review. 
hensive work upon this legitimate 




fll^dical Periodicals and Combinations. 

jHE student cannot begin too early in his course a habit of reading 
current medical literature. In this way he will best acquire an 
intelligent interest in the vital questions of his profession, secure 
a vast fund of information which will constantly supplement the 
knowledge gained from text-books, and become familiar with the 
approved methods of calling public attention to such additions as he may 
make to medical science during his professional life. For these purposes the 
following periodicals are most admirably adapted : 

THE MEDICAL NEWS (Weekly, $4.00 per Annum). 

The News contains each week twenty-eight quarto pages, comprising 
original articles, clinical lectures and notes on practical advances, latest 
hospital methods, summaries of progress condensed from the best medical 
journals of the world, full abstracts of important articles, able editorials on 
current topics, book reviews, medical correspondence from important cen- 
tres, and news items of interest. Published for fifty years, The News is 
familiar with the needs of medical men and the best methods of meeting 
them. 

THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES 

(Monthly, $4.00 per Annum). 

The American Journal is a medical magazine affording, in the 128 
pages of each issue, ample space for elaborate original articles on important 
medical discoveries, discriminating reviews on valuable medical literature, 
and classified summaries of progress. According to the highest literary 
authority of the profession, ' ' from this file alone, were all other publica- 
tions of the press for the last fifty years destroyed, it would be possible to 
reproduce the great majority of the real contributions of the world to 
medical science during that period." 

COMMUTATION RATE. 

Taken together, The Journal and News form a peculiarly useful 
combination, and afford their readers the assurance that nothing of value 
in the progress of medical matters shall escape attention. To lead every 
reader to prove this personally the commutation rate has been placed at the 
exceedingly low figure of |7.50. 

SPECIAL COMBINATION OFFERS. 

The Medical News Visiting List (regular price, $1.25), or The 
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vance-paying subscribers to either or both of these periodicals for 75 cents 
apiece; or Journal, News, Visiting List and Year-Book, $8.50. Circulara 
free on application. 



LEA BROTHERS & CO., Publishers, iJftSSJ^SSBll:^ 



Yck. 



32 







LIBRARY OF CONGRESS 

022 216 273 7 











